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COPYRIGHT DEPOSIT. 



Synopsis of 

Lectures on Obstetrics 

BY 

CHARLES SUMNER BACON 

Professor of Obstetrics and Head of the 
Department of Obstetrics 

In the College of Medicine of the 
University of Illinois 



^ 



CHICAGO: NINETEEN HUNDRED AND THIRTEEN 



Q* ip 



** 



Copyright 1913 

BY 

Charles Sumxer Bacon 



American Medical Association Press 
CHICAGO, 1913 



©C1.A357338 



THE PURPOSE OF THIS SYNOPSIS AND SUGGESTIONS 
CONCERNING ITS USE 



This synopsis was originally a collection of catch-words that 
I used in my lectures to recall the most important particulars 
of the subject to be presented to the class. It occurred to 
me that a copy of these catch-words in the hands of the 
student might help him in following the lectures and in review- 
ing the subjects for quizzes, and that it might also be of some 
value for hasty reference in subsequent obstetrical practice. 
In printing the synopsis it seemed desirable to add at times 
some data not easily remembered or such as were given 
differently by different authors; also, some subjects were 
somewhat elaborated when I found it necessary to present 
views not given in text-books or in those accessible to 
the students. Examples are: the discussion of position and 
station, of the mechanism of labor and of the physiology 
and pathology of lactation. 

"It" was first published in 1904 and a revision made two 
years later. In bringing it up to date I have rearranged the 
matter, separating normal obstetrics from abnormal for the 
convenience of the classes. As before, blank pages are left for 
notes which may be made in ink. 

To facilitate the use of the four text-books especially recom- 
mended I have also given the pages where each subject is dis- 
cussed. These books are by De Lee, 1st edition (marked D) ; 
Edgar, 3d edition (marked E) ; Hirst, 7th edition (marked H). 
and Williams, 3d edition (marked W). The excellent works 
of Webster and Davis and the symposiums edited by Jewett 
and Peterson are also recommended to the students, but not 
here referred to as no recent editions have been issued. 

The habit of arranging one's knowledge in logical order is 
desirable and such a skeleton or framework as this little 
synopsis should aid in such arrangement. Where two or more 
students room or study together it is desirable that they pro- 
cure for common use books by different authors. It is well 
for the student to get the views of two or three of the best 
authors and compare them with those presented in the lecture 
room, for in this way he will obtain broader views of his 
own and begin to form independent judgments. This will 
offset any possible danger that he may become confused when 
he finds conflicting authorities and enable him to make the 
most of the theoretical study which is the best possible founda- 
tion for practical work. 

Charles S. Bacon. 

Chicago, August, 1913. 



CHAPTER I— NORMAL PREGNANCY 



EMBRYOLOGY 

D. 1-69; E. 27-73; H. 72-131; W. 9^-168. 

Ova. — Origin and development in ovary; primordial ova, 
number, distribution and growth; formation of Graafian 
follicles, growth, cells, discus, fluid; rupture of follicles, 
ovulation; size, 60 to 200 microns. 

Structure, protoplasm, nucleus 30 microns, nucleolus 9 
microns, zona pellucida. 

Corona, follicle cells. 

Maturation, formation of female pronucleus by extrusion 
of polar bodies, relation of process to parthenogenesis, 
relation of polar bodies to embryomas. Unfecundated 
ova, destroyed in peritoneal cavity, pass through tube 
and uterus, may live several days. 

Menstruation. — Cyclic changes in the uterus and other parts 
of the body, premenstrual, menstrual and postmenstrual 
periods, endometrial changes during each, dependent on 
the ovaries but not on ovulation, relation to conception 
and nidation, corpus luteum of menstruation and preg- 
nancy, puberty, menopause. 

Spermatozoa. — Number, nuclei, spontaneous movements, in- 
semination, migration, penetration of ovum, male pro- 
nucleus. 

Fertilization. — Formation of segmentation nucleus by pene- 
tration into ovum of one spermatozoon which as male 
pronucleus unites with female pronucleus, in tube or on 
surface of ovary, beginning of germinal period which 
lasts about eight days. 

Segmentation. — Karyokenesis, morula, blastodermic vesicle, 
germ layers, viz: epiblast or ectoderm, mesoblast or 
mesoderm and hypoblast or entoderm, trophoblast. 

Blastodermic Vesicle. — Embryonic area and shield, primitive 
streak and folds, medullary groove and folds, neurenteric 
canal, somatopleure and splanchnopleure, coelom. 

Migration. — Into tube, through tube, through uterus, dura- 
tion, forces. 



Embryology 

Implantation or Nidation. — Three to seven days after fertil- 
ization, phagocytic action of trophoblast, erosion of epi- 
thelium and vessels, fibrin plug at point of entrance, 
nature and function of primitive chorionic villi, origin 
of first maternal blood sinuses, placentation begins. 

Decidua. — Vera, serotina or basilaris, reflexa or capsularis. 
compact and spongy layers, decidual cells. 

Chorion. — Formation from the extra -embryonic portion of 
the vesicle wall that does not enter into amnion, com- 
posed of epiblast and mesoblast. 
Villi originate as trophoblast projections into which meso- 
blast tissue and vessels penetrate, covered with syncy- 
tium and Langhans cells. Meaning of frondosum and 
leve\ 

Amnion. — Development of sac, ectoderm and mesoderm. 
Liquor amnii — origin: transudation, secretion; amount: 
200 c.c. to 2,000 c.c; function: protective and nutritive. 

Allantois. — From hindgut, carries vessels to chorion in some 
animals, in man only to umbilical stalk. 

Umbilical pedicle. — Belly stalk, found early in man, carries 
vessels to chorion, forms basis of cord. 

Yolk sac. — Umbilical vesicle, persists between membranes, 
its stalk in cord; intra-abdominal portion generally dis- 
appears, sometimes persists as Meckel's diverticulum. 

Cord. — Structure, umbilical stalk, allantois stalk, yolk sac 
and stalk, vessels, Wharton's jelly. 

Placenta. — Structure, maternal and fetal parts, syncytial 
buds, lacunar, invasion of stroma and vessels; function, 
nourish child, remove waste, filter. 

Embryo. — Development from second to sixth week inclusive, 
organogenesis, especially heart and blood-vessels, limbs, 
eyes, ears, nose and mouth, intestinal tract. 

Fetus. — Development of organs, circulation, functions, size 
at various four-week periods, age determined approxi- 
mately by length, 1, 4, 9, 16, 25, 30, 35, 40, 45, 50. 
Physiology, circulation, respiration, digestion, renal secre- 
tion, motion, mental action, rest and exercise, sleep. 

Heredity. — Galton's law of ancestral heredity. Biometrical 
method. 

Mendelian heredity. Character units or factors, gameto- 
genesis, zygosis, dominant and recessive characters, 
segregation, allelomorphism, homozygote, heterozygote, 



4 Changes of Pregnancy 

purity of type, difference in filial generations, discon- 
tinuity, number of unit characters. Mendelian inher- 
itance in man of abnormal and pathological characters. 
Ettles for collecting evidence. 

DURATION OF PREGNANCY 
D. 112-113; E. 127-131; H. 139-164; W. 201-207. 

How to determine probable date of labor: exact time of 

fertilization unknown; determination of end important. 

practically and legally; reckoned in days, weeks and 

months; disadvantage of the term month. 
Conception: two hundred and seventy four days. 
Menstruation: two hundred and eighty days; use tables; 

count back. 
Nausea: thirty-four to thirty-seven weeks from date of 

beginning. 
Fetal movements: one hundred and fifty- four days from 

first appearance. 
Individuality of period, therefore value of previous records. 
Size of uterus especially after twenty-fourth week when 

fundus reaches navel. 
Prolonged pregnancy; missed labor, uterine inertia. 

CHANGES OF PREGNANCY 

D. 70-111; E. 73-103; H. 131-139; W. 168-188. 
UTERUS. 

Enlargement. — Surface increased from 1 square decimeter to 

20 square decimeters, or twenty times. 
Weight increased from 45 gm. to 900 gm., or twenty times. 
Capacity increased from 2 c.cm. to about 5 liters. 
Vertical diameter increased from 4 cm. to 32 cm., or eight 

times (including the cervix from 7 cm. to 35 cm., or five 

times ) . 
Transverse diameter increased from 4% cm. to 22% cm.. 

or five times. 
Antero-posterior diameter increased from 2% cm. to 22% 

cm., or nine times. 
Walls remain about the same thickness, thin in latter 

part of pregnancy. 

Changes of Form and Consistence. — First pyriform, then 
spherical, then development of the upper portion so that 
round ligaments come from some distance below the 
fundus. In early pregnancy there is projection at site 
of egg; also Hegar's sign. Later, development of lower 



6 Changes of Pregnancy 

segment; posterior portion also develops more so that 
round ligaments converge above. Frequently irregular 
and asymmetrical shape. 

Changes of Situation. — First sinking, anteflexion; rising out 
of pelvis at twelve to sixteen weeks, fundus reaching 
navel at twenty-four weeks, sinking at thirty-eight 
weeks. 

Inclination: frequently to right. 

Longitudinal axis of uterus depends on position of patient 
and distension of abdominal walls or pendulous abdo- 
men. 

Rotation: anterior face to right. 
Cervix. — Slightly elongated. 

Situation or direction: early to one side, later somewhat 
posterior. 

Softening. 

Effacement: last two weeks. 

Muscular Wall. — Fibers increased in number and size, 50 
microns to 500 microns in length and 5 to 10 microns in 
thickness. 
Arrangement hard to determine, generally described in 
three coats, a. External: transverse, longitudinal and 
circular fibers passing from ligaments and tubes, b. 
Middle coat, fibers surround vessels, c. Internal coat, 
fibers surround tubal and cervical openings. Upper or 
contracting and lower or dilating uterine segments. 

Elastic Tissue. — Greatly increased in amount, especially in 
the outer part of the wall. Interstitial connective tis- 
sue is thicker, juicier and the fibers farther apart. 

Mucous Membrane. — Decidua. 

Serous Membrane. — Greatly increased in surface, thicker. 

Vessels. — Arteries, veins and lymphatics increased in number 

and size. 
Properties and Functions of Uterus. 

Contractility: increased especially in last half of preg- 
nancy. 
Distensibility : also increased. 
Menstruation : cessation. 

LIGAMENTS. — Elongated, hypertrophied, more vertical, more 
vascular, broad ligament unfolded. 

OVARIES. — Elevated with broad ligament, nearer uterus, en- 
larged, cessation of ovulation, function of corpus luteum 
important: Born-Fraenkel theory. 



8 Diagnosis of Pregnancy 

TUBES. — Changes in position, enlargement. 

PELVIC FLOOR.— Some hypertrophy, sinking. 

VAGINA. — Hypertrophy, congestion or dilatation of capil- 
laries, changes in color, increased secretion, bacteriology. 
Secretion: quantity, consistency, color, reaction, flora, 
bactericidal. 

VULVA. — Congested, change in color. 

PELVIC ARTICULATIONS.— Softened, lengthened, more elas- 
tic, allowing more movements of bones. 

ABDOMINAL WALLS. — Distension, influence of position and 
bandage, striae, linea nigra, diastasis of recti. 

BREASTS. — Enlargement, Montgomery's glands, secretion, 
areola both primary and secondary. 

HEART. — Displaced, increased in size ( ? ) . Pulse not changed 
in rapidity, tension slightly increased in latter part. 

BLOOD. — Slightly changed. Amount increased, reds not 
changed, slight leucocytosis, slight decrease in alkalin- 
ity, no change in molecular concentration, presence of 
ovular products, Abderhalden's test. 

THYROID. — Increased in size in later part, especial enlarge- 
ment in old nephritis, no enlargement in acute albumin- 
uria. 

KIDNEY. — Urine, increased, question of toxicity; albuminuria, 
how frequent in pregnancy, labor and puerperium. 
Kidney of pregnancy, differs from nephritis. Salts and 
form elements in urine. 

BLADDER. — Displaced, frequent micturition, causes. 

STOMACH.— Emesis, indigestion. 

BOWELS.— Constipation. 

MENTAL AND NERVOUS CHANGES. 

SIGNS OF PREGNANCY. DIAGNOSIS 

D. 250-269; E. 103-128; H. 1^2-169; W. 188-201. 

Probable Signs. — Physiological and pathological changes, 
biologic or serum reaction. 

Positive Signs. — Presence of fetus: outlines, head, limbs, etc.; 
movements, objective and subjective; heart tones, some- 
times heard before quickening. 

Differential Diagnosis. — Tumors, pseudocyesis, extrauterine 
pregnancy. 



10 Multiple Pbegnancy 

MULTIPLE PREGNANCY. TWINS, TRIPLETS, ETC. 

D. J,G2->,72; E. 533-o37; II. 110-120: W. 368-379. 

Frequency.— Twins (Veit) I: 89, Triplets I: 8,000. Influ- 
ence of country, heredity. 

Origin. — Two Graafian follicles, two ova in one follicle, two 
nuclei in one ovum, division of nucleus. 

Superimpregnation or simultaneous fecundation. 

Superfecundation or successive fecundation: fertilization 
of two ova of same ovulation or before implantation, 
proof. 

Superf etation : fertilization of two ova of different ovula- 
tions or after implantation of one of them, proofs. 

Arrangement of Membranes and Placentas. — Cords. 

Signs and Diagnosis. — Size of uterus, auscultation, palpation. 

Termination. — Premature frequent, increase disease of 
mother, fetal abnormalities. 

MANAGEMENT OF PREGNANCY 

D. 22.5-231; E. 170-175; H. 11,0-1 > t 2; W. 207- 213. 

Engagement. — Fee, should depend on (1) time consumed. 
(2) responsibility, (3) visits, (4) operations. Make 
reductions when necessary. Fees are generally too low: 
therefore, poor obstetric work. 
Physician is not obliged to take a case. Engagement 
creates a contract with obligations. Physician must 
possess necessary skill, science and information, and use 
due care and dilligence and best judgment. Duty to 
instruct patient or nurse. Must continue attendance. 
Right to leave practice temporarily if substitute is pro- 
vided. Liability for malpractice of substitute, for 
gratuitous services and for students and nurses. 

Nurse. — Physician's assistant, and should be engaged and 
trained by him. 

Examination. — Records, card system best, anamnesis, phy- 
sical examination, including measurements. See page 38. 

Patient's Outfit. — Described under labor. 

Baby's Outfit. — Described under infant. 

Exercise. — Walking, riding automobile, street car; sewing 
machine, sweeping, etc., should not get tired. 

Travel. — Railroad and ship, advantages and dangers, value of 
change of scene. 



12 Management of Pregnancy 

Factory Work. — Laws in different countries, efforts to secure 
vacation with continuance of wages during latter part 
of pregnancy. 

Bathing. — Warm and cold baths, care of breasts and nipples. , 
douches unnecessary. 

Clothing. — Warm underclothing, light overclothing, skirt 
supported from shoulders, corsets, bandage, shoes. 

Diet. — Mixed best, number of meals, effect of antifat diet on 
baby, diet in emesis and toxemia and kidney disease. 

Care of Bowels. — Fruit and food, laxatives, enemata. 

Urine. — Examine three or more times, amount, specific grav- 
ity, albumin, sugar, indican, urea, casts, etc. 

Sexual Intercourse. — Care at dates corresponding to early 
menstrual periods on account of danger of abortion; in 
latter part, danger of infection. 

Prevention of Infection. — Notify patients to avoid auto- 
examination and prevent examinations by others. 

Maternal Impressions. — No basis, harmful superstition. 



CHAPTER II— NORMAL LABOR 



DEFINITIONS 



Labor, accouchement, confinement, premature, at term. 

retarded, missed, precipitate, slow, etc., spontaneous, 

artificial. 
Normal (eutocia) : normal forces, passenger, passages, 

and mechanism. 
Abnormal or pathological (dystocia). 

STAGES OF LABOR (PERIODS) 

D. 116-129; E. Jfl5-.' f 21 ; H. 173-182; W. 233-2 J,3. 

Preparatory Stage. — Precursory symptoms. 

Increase in the uterine contractions of pregnancy which 
are sometimes painful. 

Sinking of uterus, date, causes, effects; favorable and un- 
favorable. 

Vaginal discharge. 

First Stage. — Dilatation of cervix: duration in primiparae 
and multipara*. 

Second Stage. — Expulsion of child: duration in primiparae 
and multiparae. 

Third Stage. — Expulsion of placenta and membranes (after- 
birth) : duration in primiparas and multiparas. 

EXCITING CAUSES OF LABOR 

D. 115-11S; E. Jfl3; H. 111-112; W. 226- 231. 

Stimulation of nerve centers in the uterus or in the cen- 
tral nervous system. 

a. Direct; toxins, C0 2 , fetal and placental products, ovarian 
products, menstrual periodicity, heredity. 

b. Reflex; fetal movements, distention of uterus, changes 
in placenta by infarcts, etc. 

FORCES OF LABOR 

D. 149-151; E. J,09-J,13; H. 2^9-251; W. 231-232, 2^3-262. 
UTERINE CONTRACTIONS. In all stages of labor. 

Nature of Contractions. — Intermittent: frequency and dura- 
tion. 



16 Forces of Lap.or 

General contractions of muscles of body of uterus; not 

partial nor peristaltic. 
Involuntary, yet dependent on emotions. 
Intensity: measured (a) by force required to rupture 

membranes, (b) by tocodynamometer (Schatz). 

Effects of Contractions on Mother. — 

I. Cause pain, therefore, pain is synonymous with con- 

tractions. 

Character: menstrual like, colicky. 

Location: in back, abdomen, thighs. 

Cause of pain: pressure on uterine nerves, pelvic nerves. 

Relation to pain caused by contractions of other involun- 
tary muscles. 

Variability in intensity, absence. 

II. Affect maternal circulation: congestion of face, danger 

in heart disease. 

III. Affect uterus. 

1. Harden uterus, can be determined by hand on abdomen 
or in vagina, hardening lasts longer than pain. 

2. Change situation and shape of uterus, antero-posterior 
diameter increased and transverse diameter decreased, 
ligaments also contracted. 

3. Efface and dilate cervix: generally by hydraulic pressure 
either before or after rupture of membranes, formation 
of lower uterine segment, contraction ring, BandPs and 
Bayer's theory, Schroeder's theory. 

Formation of cervical funnel and gradual changes in its 
shape. 

Dilatation of os, degree, how indicated. 

Action of bag of waters, how formed; shape, hemispheri- 
cal, pyriform, glove shape. Rupture: premature, de- 
layed, central and lateral; diagnosis of rupture. 

Condition during uterine contractions and in interval. 

4. Expel child: generally by hydraulic pressure, some- 
times by direct pressure. 

5. Separate and expel afterbirth. 

Effects of Contractions on the Child. — 

Modifies the fetal circulation, probably through action on 
the placenta. 

ABDOMINAL CONTRACTIONS 

Of value chiefly in second stage. 
Voluntary but spontaneous. 



Passages 



WEIGHT OF CHILD 



Efficiency not very great and varies with position of 
mother. 



DIFFERENT KINDS OF "PAINS" 

Precursory stage, preparatory pains, may last several 

days. 
First stage, dilating pains. 
Second stage, expelling or bearing-down pains. 
Third stage, afterbirth pains. 

After pains, may last several days. 

PASSAGES 
D. 152-166; E. 359-391; H. 17-5.' t ; W. 1-82. 

BONY PELVIS. 

Bones. — Innominate, formed by the union of three bones. 

Ilium: wing, crest, anterior superior and inferior spines,, 
posterior superior and inferior spines, body. 

Ischium: body, spine, tuberosity, ramus. 

Pubes: body, spine, ramus. 

Obturator foramen. 

Sacrosciatic notch. 

Sacrum (ossa vertebrae) : bodies, lateral masses, articulat- 
ing surfaces, shape of anterior surface. 

Coccyx. 

United by Ligaments. — Symphysis pubis. 

Saero iliac articulations (not synchrondroses). 
Sacro cocygeal articulation (anchylosis abnormal). 

False or Large Pelvis. — Boundaries. 
Shape of crests, 

Distance between spines and crests, 23 and 26 em., how 
measured. 

Pelvic Cavity. — Small or true pelvis. 

1. Boundaries. 

2. Form, truncated, irregular curved cylindroid. 

3. Inlet or brim, superior strait (not a plane). 
Shape. 

Promontory, linea terminalis or ileo pectineal 



20 Passages 

Diameters. — Antero posterior or conjugata vera anatomica. 
or promento pubio superior or p. p. s. equals 11.5 cm. 
Effect of Walcher position in changing the length. Con- 
jugata vera obstetrica or c. v. obst. or promentopubio 
minima or p. p. m. equals 11 cm., how determined. 

Conjugata diagonalis or c. d. or promentopubio inferior 
or p. p. i. equals about 13 cm. Depends on depth and 
inclination of symphysis. Method of measuring. 

External conjugate or Baudeloque diameter or d. B. equals 
about 20 cm., how measured. 

Transverse, or d. tr. equals 13.5 cm. 

Oblique or diameter sacroiliaca eminentia ilio pectinea 
equals 12.5 cm. First oblique is German and English 
right oblique and Latin left oblique, i. e. from right%>os- 
terior to left anterior. Second oblique is German and 
English left oblique and Latin right oblique. 

4. Obstetric strait or strait of ischial spines or strait of 
Bitgen or angustia. 

Definition. 

Diameters. — Anteroposterior or sacropubio inferior equals 

11 cm. 
D. bisischiatica equals 10.5 cm. 

5. Pelvic outlet or pubio-coccygeo-tuberous surface. 
Definition. 

Diameters. — Anteroposterior equals 9 to 11.5 cm. Trans- 
verse equals 12 cm. 

6. Pelvic cavity or excavation. 
Depth. — Anterior wall, 4 cm. 

Posterior wall or from promontory to end of sacrum, 10 
cm. 

Medium depth from brim to ischial spines equals 7.5 cm. 

Other dimensions. — Antero posterior and transverse diam- 
eters equal about 12.5 cm. 

Parallel planes of Hodge. 

7. Inclination of pelvis: angle which p. p. s. makes with 
the horizon, equals about 60 degrees. 

Variations on account of position, e. g\, back, lithotomy, 

knee-chest, etc. 
Normal erect position: anterior spines and pubic spines in 

vertical plane. 
Inclination of outlet about 10 degrees. 
Normal inclination, Meyer's line, equals 30 degrees. 

8. Axes: axis of inlet, axis of outlet, axis of pelvis, line of 
progression. 



22 Passaces 

Variations in Pelvic Cavity. — 

1. Normal. — Due to: 
Individuality. 

Sex: male pelvis is smaller especially at outlet. 

Race: variation in form. 

Age: fetal and infantile pelves straighter. changes in 
adult pelves due to developmental and mechanical fac- 
tors. 

2. Pathological. — Due to: 
Developmental anomalies. 
Disease: rickets, osteomalacia, etc. 
Injuries: fractures, dislocations, etc. 

SOFT PARTS CONNECTED WITH BONY PELVIS. 

Connected with Large Pelvis. — 

Muscles, iliacus and psoas; vessels; nerves. 
Change shape of inlet. 

Connected with Pelvic Cavity. — Pyriformis and obturator 

internus, origin, fascia, relations. Nerves and vessels. 

Bladder and rectum. Viscera, including ovaries, tubes, 

uterus, vagina. 
Connected with Pelvic Floor and Outlet. — Close pelvic cavity 

below, forming pelvic diaphragm, and extend obstetric 

canal. 

1. Coccygeus and levator ani, including ilio-coccygeus, 
pubococcygeus and puborectalis; attachments, relations 
to rectum and vagina, functions. 

2. Urogenital trigone : attachments, functions, perforations. 
3'. Accessory muscles; in anal region, sphincter ani ex- 

ternus; in urogenital region, transversus perinei, ischio- 
cavernosi, bulbocavernosi. Definitions of perineal region, 
anal region, urogenital region, perineum. 

OBSTETRICAL CANAL. STATION OR STATIO 

The- obstetrical canal is gradually formed during labor as 
the presenting part advances by the dilatation of the 
uterus, vagina and pelvic diaphragm and the distention 
of the perineum. For purposes of description it is desir- 
able to consider it as preformed. In this sense it is a 
cylindrical cavity. Its upper part, from the inlet to 
below the second parallel plane of Hodge is straight 
while the rest is curved. 

Its upper half is enclosed within the walls of the bony 
pelvis and its lower half, the vaginovulvo perineal tube. 
is below the bony pelvis and forms an extension of the 



24 Passenger 

upper part. This canal is, therefore, divided into two 
nearly equal parts by the obstetrical straits and 
bounded above by the pelvic inlet and below by the 
vulvar orifice. Practically the vaginal tube and the 
vulvar opening may be considered together as forming 
the obstetric outlet. Both the orifice and the tube are 
dilated together and usually do not retain the head long 
after its passage through the straits. 

Station is a term used to denote the station, situation or 
location of the head or other presenting part of the 
fetus. It is important to determine and designate the 
location of the passenger in order to denote the progress 
of labor, to make an accurate prognosis and to decide 
upon operative interference. 

We may say that there are in the obstetrical canal four 
stations or sites where at any given moment the head 
may be located and through which it must pass. These 
are: 

1. The inlet or aditus, contraction ad. 

2. The excavation or pelvic cavity, contraction, excav. 

3. The straits or angustiae, contraction ang. 

4. The outlet or exitus, contraction ex. 



PASSENGER 

D. 167-180; E. 391-1,09; H. 21,6-252; W. 213-220. 

HEAD. 

Skull or cranium and face. 

Bones. — Especially occipital, parietal, frontal, temporal. 

Sutures. — Allow molding; sagittal or anteroposterior; 
transverse or frontoparietal or coronal; lambdoid or 
occipitoparietal. 

Fontanelles. — Large or anterior or bregma, small or pos- 
terior. 

Diameters. — Maximum, from middle of chin to most distant 
point of skull, 13.5 cm. 
Occipitomental or o. m. is 13 cm. 
Occipitofrontal or o. f. is 12 cm. 
Suboccipitobregmatic or s. o. b. is 9.5 cm. 
Suboccipitofrontal maximum or s. o. f. is 9.7 cm. 
Bitemporal or bi. t. is 8 cm. 

Circumferences. — Maximum is 37 cm.; s. o. b. is 32.5 cm.; 
s. o. f. is 33 cm. 



20 Passenger 

Names of Regions. — Occiput is the region of the occipital 
bone. 
Vertex is the region of the sagittal suture between small 
and large fontanelles or between the lambdoid and 
coronal sutures. It may be divided into posterior, mid 
and anterior. 
Sinciput is the region between coronal suture and root of 
nose, includes forehead. 

TRUNK. 

Size, less than head, abnormal size rare. Diameter bisac- 
romial 12 to 9 cm. Diameter sternodorsal about 9 cm. 

HIPS AND EXTREMITIES. 

Diameter bicristal or bisiliac about 8 cm. 
Diameter bitrochanteric about 9 cm. 
Diameter dorsopubic about 5 cm. 

ATTITUDE OR POSTURE OR HABITUS. 
Definition. 

Flexed, ventral flexion usual; causes, developmental ten- 
dency, pressure of uterus. 
Deflexed or extended or dorsal flexion. 
Inclined or lateral flexion. 

PRESENTATION OR PRESENTATIO. 

Definition. Indicates attitude. 

Variations during pregnancy and during different stages 

of labor. 
Head, trunk, breech. 

Head. — Frequency, 96.5 per cent, at term, less common be- 
fore term. 
Cause, greater weight of head ( ? ) , accommodation to 
uterine cavity. 

1. Skull, or cranial, 96 per cent. 

Occipital, rare at inlet, common at straits and outlet., 
denotes complete flexion. 

Vertical, most common at inlet and during descent. 

Sincipital, includes brow which is rare, considerable de- 
flexion. 

Parietal bone, anterior or posterior, not uncommon above 
inlet before labor begins. 

2. Face, .5 per cent.; greatest extension of head, also ex- 
tension of trunk. 



2S Passenger 

Trunk.— About .5 per cent. 

Causes, shape and obliquity of uterus. 
Kinds, shoulder, arm, etc. 

Breech. — About 3 per cent, at term. Complete, foot, knee, 
etc. 

POSITION OR POSITIO. 

Definition. — General or broad, relation of fetus to mother 
or relation of any determining point of the fetus to the 
obstetrical canal. In this sense includes presentation 
which is relation of fetus to axis of obstetrical canal. So 
we have longitudinal and transverse positions. 

Restricted or usual, relation of a determining point of the 
fetus to the sides of the obstetrical canal. In this sense 
independent of presentation and attitude. The deter- 
mining point may be any point on the body. We gener- 
ally use the back or some point on the head, generally 
occiput or chin. 

Position varies during pregnancy and during labor. Posi- 
tion of head and trunk may vary independently of each 
other. If we wish to denote the position of the trunk 
we use the back as the determining point. When we 
denote the position of the head we may always use the 
occiput. 

Designation of Position by Naming from the Back. — During 
pregnancy or before the head enters pelvis when by 
external examination we are not certain of position of 
head. 

Back left, left anterior, left posterior, anterior, posterior, 
right, right anterior, right posterior. 

Latin designations and abbreviations best. 

Positio dorsalis laeva anterior or dextra anterior, posterior, 
etc. 

Contractions, pos. d. a., d. 1. a., d. 1., d. 1. p., d. p., d. d. p 
d. d., d. d. a. 

Keep to proper order of modifying terms, not 1. d. a., etc. 

Designation of Position of the Head by Naming from the 
Occiput. — Positio occipitalis laeva anterior, positio occipi 
talis dextra posterior, etc. 

Contractions pos., o. a., o. 1. a., o. 1., o. 1. p., o. p., o. d. p. 
o. d., o. d. a. 

Sometimes we use occipitalis pubica for o. a. and occipi 
talis sacralis for o. p. 

Since position means only the relation of a point in the 
back or head of the fetus to the obstetrical canal and is 
independent of the attitude or presentation of the fetus. 



30 Passenger 

we would better always use the same method of denot- 
ing position whether head is well flexed or completely 
extended, that is, whether the presentation is occiput, 
vertex, sinciput or face we use the occiput to name the 
position. It is not necessary to touch the occiput to 
know where it lies. That we find by examination of the 
sagittal suture and fontanelles. Hence we denote pre- 
sentation and position thus, presentatio occipitalis, ver- 
ticals, facialis, etc., positio occipitalis Leva anterior 
when we have to do with most common position. 

Designation of Position by Naming from the Chin. — In case 
of face presentation most authors and teachers use the 
chin as naming point. Thus we have positio mentalis 
laeva anterior, dextra posterior, etc., or contracted m. 1. 
a., m. d. p., etc. Others use other points, for instance, 
the sinciput, the brow, etc. This is all confusing and 
has no value. 

Designation of Position in Breech and Cross Presentation.— 
In breech presentation position is generally designated 
by using the sacrum as designating point. This is not 
necessary, for the dorsum answers every purpose. 
In cross presentation the scapula may be used, but in these 
rare cases we may quite as well specify the location of 
the head. 

Frequency of Different Positions. — With head presentations 
during pregnancy the back is directed to the left in 
about two-thirds of all cases. Here it is more frequently 
found anterior. 
When directed to the right it is more often posterior. 
At the inlet positions are approximately o. 1. a. oo per 
cent., o. 1. p. 10 per cent., o. d. a. 15 per cent., o. d. p. 20 
per cent. 

STATION. 

The head is not a point, but a body having considerable 
diameter. Hence, even with good progress some portion 
of it will be in one of the straits or cavities for some 
time. To define the location of the head we say that it 
is in one of the straits until its greatest circumference 
has passed through. 

With complete flexion, i. e., an occipital presentation, the 
greatest circumference is s. o. f. Hence, the head is in 
aditu until this circumference has passed the inlet. It is 
in excavation until rotation has occurred, then in angus- 
tia until the s. o. f. circumference has passed this strait, 
and finally in exitu until its expulsion from the body. 



32 Mechanism of Normal Labor 

With vertex presentation the largest circumference is o. f., 
which must likewise pass the inlet before the head has 
entered the pelvis, etc. In face presentation it is the 
s. m. o. circumference which is greatest and determines 
the station of the head. 

EXAMINATION FINDINGS. 

The complete designation of the practically important find- 
ings in an external examination includes: 
1 Nature and frequency of the uterine contractions. 

2. Location, nature and rate of the fetal heart tones. 

3. Presentation of the child. 

4. Position of the child. 

5. Station of the head. 

6. External measurements. 

In an internal examination the points to be determined 
are: 

1. Condition of the vagina. 

2. Degree of dilatation and effacement of the cervix. 

3. Condition of the membranes. 

4. Presentation. 

5. Position. 

6. Station. 

7. Presence or absence of abnormalities in the pelvic 
dimensions with measurement of the p. p. i. diameter. 

MECHANISM OF LABOR 

D. 181-203; E. ^21-4^3 ; H. 2^5-262; W. 262-2S2. 

In normal or skull presentation the mechanism of labor 
is the way in which the passenger is moved through 
the passage by the forces of labor. Three kinds of 
movements of the fetus occur, viz., translation, flexion 
or extension on any transverse axis and rotation. The 
progress may be described in four steps. 

First Step, Descent. — Entrance into pelvic excavation or 
passage through inlet, engagement partial and com- 
plete, definition of. 

Generally the sagittal suture is in an oblique diameter. 

Descent is often preceded by or accompanied with flexion 
which is due to lever action, the long arm of the lever 
being the fore part of the head, or the long axis of 
the head elipsoid i. e., the o. m. diameter tends to coin- 
cide with the axis of the obstetrical canal. 

Synclitism, Naegele obliquity, Varnier obliquity. 



34 Management of Normal Labob 

Molding of head, caput succedaneum. Also rotation may 
begin. 

Second Step, Internal Rotation. — Due to accommodation to 
canal, action of pelvic floor or levator ani and the action 
of the fetal body. 

Sellheim's theory. The fetus tends to bend in some direc- 
tions instead of in others. The head bends most easily 
backwards while the body tends to lateral flexion. 
These facts are proven by observations on the newborn 
child. When passing through the obstetrical canal the 
fetus obeys the law that "When a body capable of 
rotating, which tends to bend in one direction, passes 
through a bent canal it will rotate till its line of great- 
est flexibility coincides with the axis of the canal." 

Completion of flexion. 

Variations in rotation in pos. o. 1. a., o. 1. p., o. d. a. and 
o. d. p. 

Third Step, Exit of Head. — Passage of head through straits 

and vaginal outlet. 
Gradual change in direction. 
Distention of perineum, separation of labia, passage of 

occiput under pubes, extension of head and escape from 

vulva, molding of head. 

Fourth Step, Exit of Body. — External rotation of head 
with internal rotation of body, passage of straits by 
shoulders, passage of anterior shoulder under symphy- 
sis, escape of posterior shoulder, passage of body and 
hips. 

MECHANISM IN THIRD STAGE. 

D. 12S-129; E. .',19-',21 ; H. 290-201; W. 300-306. 

Duncan and Schultze, separation and expulsion of pla- 
centa from uterus, expulsion from lower uterine segment 
and from vagina. 

MANAGEMENT OF LABOR 

D. 231-2.i,9, 270-320; E. 131-170, J h ',.' t --',7 1 ; H. 170-19S; 
W. 311-339, 701-715. 

HOSPITAL OR HOME. 

Advantages of hospital. — Sufficient assistance and supplies, 
more perfect asepsis, better observation before and after 
labor, saving time of the physician. 

PREPARATORY ARRANGEMENTS. 

Preliminary examination, including measurements in preg- 
nancy, record book, choosing and preparation of room, 
engagement of nurse. (See management of pregnancy.) 



36 Management of Normal Labor 

Patient's Outfit. — Twenty-five yards sterile gauze, 4 pounds 
absorbent cotton, rubber sheeting 11/4x1% and 1^x1% 
yards, 4 yards cotton cloth (for bandages), 1 bottle (25) 
sublimate tablets (7+gr. each), 3 ounces compound 
solution of cresol (lysol), 1 ounce olive oil, some prepa- 
ration of ergot for hypodermic use, 1 pint alcohol, 250 
grams ether, 1 tube antiseptic soap, 2 nail brushes, 1 
nail file, 1 bath thermometer, 1 envelope sterilized silk 
ligature, 1 glass irrigator point, 1 water nursing bottle. 

1 3-oz. rubber syringe, fountain syringe (3 quarts), 
enamel bedpan, enamel douche pan, enamel baby bath 
tub, breast pump, nipple shield. 

Other necessary preparations : 8 sheets, 12 towels, pillow- 
slips, patient's shirt, gown, leggings or stockings. Oil 
cloth (2x2 yards) for the floor if carpeted, large stand 
or small table, 2 enamel washbowls, 1 small (finger) 
bowl, 1 slop jar or pail, 2 pitchers, 1 or 2 glass fruit 
jars for salt solution, 2 or 3 gallons of hot and as much 
cold boiled water. 

Minimum outfit which for emergency cases it may be 
desirable for the physician to carry: 1 rubber sheet, 

2 cotton sheets, 6 towels, 5 yards gauze, 1 pound absorb- 
ent cotton, 1 bottle (25) sublimate tablets, 1 ounce 
F. E. ergot, soap, nailbrush, silk ligature, 2 basins. 

Baby's Outfit.— See Chapter IV. 

Obstetric Bag. — Sterilizer. 

General sack: scissors, needle forceps, long forceps, dress- 
ing forceps, tenaculum forceps, 2 retractors, silver 
catheter, intrauterine douche tube, razor. 

Examination sack: pelvimeter, tape line, phonendoscope, 
scales. 

Forceps sack: forceps. 

Rubber sack: set Voorhees dilators, bulb syringe, aspirat- 
ing catheter, rubber urethral catheter. 

Embryotomy sack: Auvard cranioclast, Braun hook. 

Abortion sack: dilators, curette. 

Case for needles, catgut, silk, silkworm gut, fountain 
syringe, gloves, rubber apron, rubber sheet, gown, gauze, 
cotton, ether, ergotole, sublimate tablets, salt tablets; 
silver solution, collodion, soap, brushes, file, hypodermic 
syringe and tablets, thermometer. 

ANSWER TO CALL. 

Arrival at house, supervision of nurse and her arrange- 
ments. (For legal responsibilities see Management of 
Pregnancy. ) 



3S Management of Normal Labor 

PREPARATION OF SELF. 

Cleaning of hands, Fuerbringer method, gloves and gown, 
gnaze cap and mask for hair and month. 

PREPARATION OF PATIENT. 

Before labor: baths (sponge, tub, shower), laxatives, 
injections, washing hair, enema, use of closet. 

Dress of patient : shirt, short gown, stockings or long feet 
drawers, or leggings. 

Bed: rubber sheets, sheets, pads. 

Cleaning of genital region: on douche pan, clip hair or 
shave, soap and water, antiseptics, vaginal douche ( ? ) , 
vulvar pad, care of douche pan, stands, how placed and 
covered, contents, pail, douche bag, water, floor, steril- 
ize instruments, including thermometer. 

EXAMINATION OF PATIENT. 

General. — Pulse, temperature, headache, edema, blood- 
pressure. 

Special. — 

Objects: 1. Determine condition of passages, that is, pelvis, 

cervix, vagina, membranes, etc. 
2. Determine attitude, position, presentation, station and 

condition of passenger. 
Methods: I. External abdominal. 

1. Inspection: size, shape and location of uterus, move- 
ments of child. 

2. Palpation: outline uterus, determine position, attitude 
and station of child; manipulations 1, 2, 3 and 4. 

3. Auscultation: fetal heart tones, importance, how taken 
and recorded, instruct nurse. 

Murmur in cord, uterine soufle. 

4. Measurement of interspinous, intercristal and Bande- 
loque diameters. 

II. External of genital regions. 

1. Inspection: discharge, liquor amnii, blood, meconium. 
Distention of perineum, appearance of head. 

2. Palpation: progress of head, behind anus. 

III. Internal examination. 

Examine vagina, cervix, os, membranes, presenting part, 
sagittal suture, fontanelles, relation of presenting part 
to spines, measure p. p. i., also note any abnormalities 
of passages or passenger. 



40 Management of Normal Labor 

POSITION OF PATIENT. 

Out of bed: dress, walking, standing, sitting, etc. 
In bed: on which side during labor, position during deliv- 
ery. 

NOURISHMENT OF PATIENT. 

Food, drink, stimulants, nausea and vomiting. 

RELIEF OF PAIN AND FEAR. 

Moral support, morphin, codein, chloral, scopolamin. 
Anesthetics: ether during labor, for operation. 
Support of back, pulling of patient. 

CARE OF BLADDER. 

Frequent attention, catheterize when necessary. 

CARE OF RECTUM. 

Sponges and washing to protect from discharge. 

PREVENT LACERATION OF VULVA AND PERINEUM. 

Laceration of cervix and vagina may be unavoidable. 
Frequency of vaginal and perineal tears, 20 to 30 per cent, 
in primiparse. 

Method of Prevention. — 

1. Flex head and bring occiput under symphysis. 

2. Prevent rapid exit of head. 

3. Episiotomy. 

Pressure on perineum useless or harmful. 

CARE OF CHILD AND SEPARATION FROM MOTHER- 
THIRD STAGE. 

D. 310-321; E. £71-477; H. 199-205; W. 306-311, 333-338. 

Wipe face, establish respiration, cleaning throat if neces- 
sary. See page 60. Keep warm and dry, use Crede 
instillation, tie cord at skin junction and cut and also 
cut cord close to vulva with or without ligating next to 
placenta, vulvar dressing. 

Hand on abdomen to control uterus, watch discharge, clean 
patient, clean the bed, inspect perineum and repair if 
necessary. 

Deliver placenta and membranes; wait one -half hour for 
spontaneous expulsion if no hemorrhage. Then, if 
secundines are in lower uterine segment or vagina, 
direct patient to use auxiliary muscles during uterine 
contraction. If necessary, reinforce the action of the 



Management of Normal Labor 

abdominal muscles by pressing - with the hand on the 
abdomen. See page 174 for operative expression from 
lower uterine segment. If the placenta remains in 
upper uterine segment, massage to cause uterine con- 
traction and expulsion. If expulsion from uterus does 
not occur in 2 hours Crede expression may be required. 
See page 172. 

Examine placenta and membranes for abnormal conditions 
and defects. 

Clean the genital region, apply vulvar dressing and abdom- 
inal binder and remove to lying-in bed. 



CHAPTER III 
NORMAL PUERPERIUM 



Definitions. — Puerperiuin, childbed, lying-in period. 
Duration.— Six to twelve weeks. 
CHANGES OF THE PUERPERIUM. 

D. 20J,-222; E. 653-667; H. 206-229; W. 339-3 J7. 
Xormal anatomical and physiological constitute involution. 
Xot far separated and often hard to distinguish from 
pathological. 

CHANGES IN THE UTERUS.— INVOLUTION. 
Change in Size. — 

Height of fundus,, gradual rise from pelvis after expulsion 
of placenta to above navel, descent, disappearance, sev- 
enth to twelfth day. 
Diameters all decreased. 

Change in Shape. — From ovoid to shape of non-pregnant 
uterus, concave anteriorly. 

Change in Position. — 
Abdominal to pelvic. 

Abnormal: anteflexion, retroversion and flexion. 
Treatment consists in knee chest position, manual replace- 
ment, pessary. 

Changes in Endometrium. — 

Degeneration, condition of placental and extra placental 

regions, disappearance of deciduse. 
Regeneration, source of new epithelium. 

Changes in Muscular Wall. — 

Atrophy and destruction of muscle cells, influence of 

phagocytosis. 
Rearrangement of muscle fibers. 

Changes in Uterine Vessels. — Formation and organization' of 
thrombi; thickening of walls of arteries. 



4fi Changes of Puerperium 

Contractions — After-Pains. 
Causes. 

Frequency in primiparse and multipara*. 
Treatment, morphin. 

Lochia. — 

Nature, blood, serum, decidua, distinction from hemor- 
rhage, changes in character during flow. 

Amount, depends on hemorrhage and other factors. 

Duration, stoppage or retention. 

Bacteria, kinds, source, location, effect on odor, on 
infection. 

Change in Cervix. — 

At first flabby cuff, later contraction scars from infection 
and tears. 

Menstruation. — Generally absent for several months and fre- 
quently during entire lactation. Sometimes reappears 
3 to 4 weeks after labor and continues more or less 
regularly. Relation to ovulation and conception. 

CHANGES IN VAGINA AND VULVA. 

Abrasions and bruises with slight infection. 
Involution of fundal and lower portions. 
Effects of tears. 

CHANGES IN LIGAMENTS. 

Subinvolution in retroversion and flexion of uterus, invo- 
lution after Alexander and other operations for dis- 
placements. 

CHANGES IN PERITONEUM. 

Involution of uterine serosa. 
CHANGES IN ABDOMINAL WALLS. 
Involution and subinvolution. 
Diastasis of recti muscles. 
Permanence of striae. 

CHANGES IN ABDOMINAL ORGANS. 

Tendency to splanchnoptosis because of lengthened mesen- 
tery and change in intra-abdominal pressure. 

URINARY SYSTEM. 

Kidney. — Disappearance of pathological changes in "kidney 
of pregnancy/' 

Ureters. — Disappearance of dilatation. 



48 Changes of Puerperium 

Bladder. — Return to pelvis and resumption of former relation 
to pelvic and abdominal organs. 

Disturbed Micturition. — 

Causes, horizontal position, change in intra-abdominal 

pressure, injuries to urethra, disturbed innervation. 
Diagnosis, external examination shows distended bladder, 

overflow from paralyzed viscus should be distinguished 

from normal urination. 
Rules for management. Patient should try to urinate 

every six to twelve hours. 
She may sit if necessary unless in dangerous condition. 
Catheterize if urination impossible, danger of cystitis. 

rules. 

INTESTINES. 

Paralysis or paresis, distention, constipation. 

Causes of Constipation. — Constipation during latter part of 
pregnancy, change in abdominal pressure, lack of exer- 
cise, horizontal position. 

Results. — Toxemia, perhaps infection, frequently most im- 
portant complication of childbed. 

Management. — 
Begin second day. 

1. Medicines, magnesium citrate, seidlitz powders, mag- 
nesium sulphate, mineral waters, cascara sagrada, senna. 
calomel. 

2. Massage. Objects, mechanically move on contents of 
bowels, stimulate peristalsis, assist action of enemata. 

Methods, hands, ball, etc., direction of movement. 

3. Enemata. Contents: water, oil, glycerin (glycerin 
suppositories), solution of salt, soap, turpentine, salts, 
etc. 

Amount, from one dram to gallons. 

Temperature, from ice cold to 115 degrees. 

Methods: piston, bulb, or fountain syringe, hard or soft 

tubes, long tubes, "colonic flushing" ( ? ) , position of 

patient. 
Removal of hard masses from rectum. 

CHANGES IN THE BREASTS, LACTATION. 
Importance. — Concerns mother and child. 

1. Sufficient and proper secretion very important to child. 

2. Danger of infection great for nursing causes abrasions 
on the nipples of most women. 



Lactation 

Anatomy of the Breasts. — Main ducts, lobes and lobules, 
acini, gland cells, distribution of lymph and blood 
vessels. 

Physiology of the Breast and Secretion. — 

Rest period, swelling and preparation of gland cells, filling 
of vessels. 

Active period, formation of milk by secretion or breaking 
clown of gland cells or both, stimulus is nursing or other 
excitant, analogy with other secretions or with milking 
in animals, most of the milk is formed during nursing. 

Clinical Phenomena. — 

Colostrum. 

Composition, difference between it and milk, valuable as 
food and laxative for child, early nursing also stimulates 
breast secretion and uterine involution. 
Establishment of Milk Secretion. 

Appearance of milk gradual, generally from second to fifth 
day. 

Congestion of the Breasts. 

Cause: distention of vessels, not curdling of milk. 
Symptoms: swelling, pain, tenderness, hardness, lumps, 

no fever. 
Results: not dangerous unless infection supervenes, only 

temporary discomfort, in nervous women loss of sleep 

and institution of unwise procedures. 
Management. 

1. Support: bandage, simple jacket, double Y bandage; 
roller bandage used especially when necessary to dry 
up the milk. 

2. Icebag or coil. 

3. Massage. 

Object is to empty the vessels of the breast and not to 

empty the milk. 
Contraindication, infection. 
Technic, position of patient and attendant, clean hands, 

lubricants, direction of manipulations. 

4. Pump: not necessary, may also do harm. 
Agalactia and Deficient Secretion. 

Causes: defective development of gland, malnutrition, 
nervous influences. 

Frequency: increasing in America. 

Treatment : mixed diet, general hygiene, medicines uncer- 
tain, frequent nursing at both breasts. 



52 Management of the Ptjerperium 

Polygalactia and Galactorrhea. 
Analogy to salivation. 

Causes: open ducts, constant stimulation, failure of inhib- 
itory centers. 
Treatment, bandage, avoid stimulation. 

CHANGES IN THE AXILLARY SWEAT GLANDS. 

Temporary hypertrophy, not important, often mistaken 
for swollen lymphatic glands or for supernumerary 
mammary glands. 

CHANGES IN CIRCULATORY SYSTEM. 
Slow Pulse. — Cause unknown. 
Blood.— 

CHANGES IN NERVOUS SYSTEM. 

Postpartum Chill. — Common, not alarming, cause. 

DIAGNOSIS OF THE PUERPERIUM. 

Medicolegal importance. 

Based on normal and pathologic changes. 

Especially, recent tears, lochia, condition of uterus, abdom- 
inal walls and breasts. 

Probable signs in primiparse and in multipara. 

Positive signs, finding parts of the ovum. 

Problem arises more frequently after abortion than after 
labor at term. 

MANAGEMENT OF THE PUERPERIUM 

D. 321-328; E. 667-677; H. 231-2kk; W. 347-35 k, 853-868. 

REST. 

Degree and length depends on (a) previous condition of 

patient, (o) temperament, (c) length and severity and 

complications of labor. 
Movement in bed not prohibited at any time unless patient 

very weak. 
Sleep desirable, should not be disturbed by baby, nurse or 

family. 
Company, restrict or prohibit. 

EXERCISE AND GETTING UP. 

Advantages of Horizontal Position. — 

Prevents congestion of pelvis and splanchnoptosis. 
Prevents subinvolution of abdominal wall. 



54 Management of the Puerperium 

Disadvantages of Inactivity in Bed. — 

Sluggish lymphatic and blood circulation, with autointoxi- 
cation. 
Weakened muscles. 

Object of Bed Exercise. — 

Overcome disadvantages and secure advantages of bed. 
Stimulate circulation and strengthen muscles. 

Character and Order of Exercise. — 

Tense or opposed flexion and extension. 

1. Breathing, five to ten times. 

2. Upper extremities, five to ten times. 

3. Feet, ten to twenty times. 

4. Thighs, three to five times. 

5. Lower extremities, three to five times. 

6. Trunk, three to five times. 

How Employed. — 

When begun, second to fifth day; frequency, three to five 
times a day; duration, two to twelve weeks. 

Walking. — 

When begun, fifth to twelfth day, one minute at a time at 
first, increase slowly, regard as an extension of bed 
exercise, stair climbing. 

Sitting.— 

Comes after walking, very gradual. 

DRESSINGS. 

Vulvar pad, sterile, wide, fastened at four corners, no 
T bandage. 

Vulvar toilet, external antiseptic douche or washing with 
sponges, use of douche pan, danger, care of. 

Abdominal bandage, how applied, advantages of. 

Breast bandage, pattern, length, width, how applied, dress- 
ing of nipple. 

Corsets, pattern, advantages and disadvantages. 

DIET. 

Vulgar errors; causes fever, etc. 

Amount. — 

Replenish loss, supply milk. 
Needs of first days. 

Frequency. — 

Five feedings a day may be desirable. 



50 Management of the Puerperiuh 

Kind.— 

Mixed best, liquid necessary, slop diet not desirable, pro- 
teids necessary, fruits good, do not hurt mother's milk. 

CARE OF ROOM. 

Temperature 70 degrees, depends on presence of baby. 

Ventilation, window. 

Odors, removed by ventilation. 

Flowers. 

Cleaning. 

EXAMINATIONS. 

Daily examinations of breasts, abdomen and vulva. In 
two weeks a thorough examination should be made and 
findings recorded and again in six weeks, before dis- 
charging the patient. Legal bearings. Distinct under- 
standing of the termination of contract. 

The complete examination should include general condition, 
color of skin, condition of mouth, neck, breasts, nipples, 
abdominal wall, perineum, vulva, anus, pelvic floor, 
vaginal discharge, uterus, size, position, mobility, sensi- 
bility, cervix, lacerations, adnexa. 



CHAPTER IV-THE INFANT 



ANATOMY, PHYSIOLOGY AND CLINICAL PHENOMENA, 
BOTH NORMAL AND ABNORMAL 

D. 829-339; E. 75> f -830; H. 9^2-972; W. 854-859, 869-873, 
93^-935. 

CIRCULATORY SYSTEM. 
Change from Fetal to Extrauterine Life. — 

Obliteration of umbilical vessels, ductus venosus, ductus 
arteriosus and foramen ovale. Establishment of pul- 
monic circulation. 
"Blue child," cause, laying child on right side unnecessary. 

Pulse. — Frequency. 

Blood. — Amount, specific gravity, reds and whites, nucleated 
reds, ferments. 

RESPIRATORY SYSTEM. 

Establishment of Respiration. — 
Cause, when, first cry. 

Apnoea. — 

Cause, diagnosis, danger. 

Asphyxia Neonatorum. — 

Definition. — Distinction from apnoea. 
Causes. 

1. Premature stimulation of respiration with aspiration of 
liquids into throat and lungs, due to pressure on cord as 
in prolapse of cord, or to separation of placenta. 

2. Gradual numbing of respiratory center, no aspiration 
of liquids, interference with placental circulation 

( tetanic contractions ) . 

3. Injury to brain, no aspiration. 
Degree. 

a. Livid or congestive asphyxia, respiration generally 
excited by cutaneous stimulation. 

b. Pallid asphyxia, respiration not excited by cutaneous 
stimulation. 



GO Asphyxia Neonatorum 

Treatment. 

1. Hold the head down and slap the body. 

2. Remove mucus with tracheal catheter. 

3. Tie cord, apply hot and cold water, using tub and 
faucet or pitcher. 

4. Byrd method. 

5. Sylvestre method. 

6. Schultze swinging, technic. 

7. Breathe air into lungs, technic. 

8. La Borde method. 

9. The pulmotor. 
Combine 4, 5, 6, 7 and 8. 

Listen to heart, continue as long as any sign of heart 

action. 
After care. 

Rapid and Irregular Breathing. — (Cheyne- Stokes.) 

Causes: general infection or intoxication, head injury, 

respiratory affections. 
Treatment: find and treat cause, baths, enemas. 

Aspiration Pneumonia. — 
Cause, prevention, treatment. 

Actelectasis Pulmonum. — 
Generally in premature. 
Treatment, incubator, oxygen. 

Respiratory Infections. — 

Coryza. 

Intrapartum and postpartum. 

Gonorrheal, catarrhal, grip. 
Bronchial. 

Catarrhal, grip. 

UMBILICAL CORD. 

Tying. — Primary, tape or large ligature, one inch from body, 
immediate or after cessation of pulsation, protect child. 
Secondary, at junction of skin, objects. 
Ligature on placental side not necesary. 

Cutting. — Leave only enough to prevent slipping of ligature. 

Desiccation and Separation. — No impervious dressing. 

Infection. — 

Causes: ligature, dressing, bath. 
Time: before and after separation. 



02 Umbilical Cord 

Point of entrance: generally at skin junction. 
Kinds: streptococcus, staphylococcus, tetanus, etc. 
Results. — 

Local, ulcer inflammation. 

General, intoxication, infection from septic thrombi in 
umbilical vein. 
Prevention. — 

Sterile ligature. 

Wash with alcohol, especially after bath. 

Sterile cotton dressing. 

Eczema. — After separation of cord, treat Avith protective 
powder. 

Umbilical Hernia. — Xot hernia into the cord. 
Causes: congenital weakness, straining. 
Prevention: bandage useless. 
Treatment: plaster. 

SKIN. 
Vernix Caseosa. — 

Nature, how removed. 

Erythema. — 

Reaction to external irritants, immunization. 

Infections. — Pimples and boils. 
Cause: dressing, bathing, etc. 
Treatment: how opened, care in bathing. 

Eczema. — Influence of overfeeding. 

"Marks," Naevi. — Vascular tumors. 

Treatment, when important and growing, acid. 

EYES. 

Co-ordination.— Xot at birth. 

Subconjunctival Hematoma.— Xo treatment. 

Infection. — 

1. Catarrhal. 

Causes: various kinds of infecting bacteria. 

a. Intrapartum: vaginal secretion. 

b. Postpartum: washes, soap, etc. 
Treatment: boric acid wash. 

2. Gonorrheal (ophthalmia neonatorum). 



04 Eyes, Mouth 

Sources. — 

Cervical or vaginal discharge, disease may remain latent 
for years in genital tract of mother. 
Prevention. — 

Crede installation, technic, used only when gonorrhea 
suspected. 
Treatment: nitrate of silver solution, consultation. 

DIGESTIVE SYSTEM. 

MOUTH AND PHARYNX. 

Tongue Tie. — Effect on nursing, operation. 
Infection. — 

a. Thrush. 

Cause : oidium albicans ( ? ) . 

Mode of infection: washing mouth, nipple, "sweet teat" 

or "comfort." 
Prevention: let mouth alone. 
Treatment: washing, technic. 

b. Gonorrheal. 
Cause and treatment. 

STOMACH. 

Size, position, function, regurgitation. 

INTESTINE. 

Meconium. — 

Nature, color, amount. 

Invasion of Colon Bacilli. — Immigration, gas formation, colic. 

Bowel Movements. — Yellow stools, odor, frequency, size. 

Diarrhea. — Excessive vermicular action, infection may be 
present. 
Treatment: calomel, castor oil, enemas. 

Constipation. — 

Generally with artificial feeding. 
Treatment: change food, enemas, oil. 

Gastroenteric Infection ( Gastroenteritis ) . 

Sources : improper and contaminated food, including drink, 

cold. 
Symptoms : colic, vomiting, diarrhea, fever, etc. 
Treatment: diet, enemas, calomel, oil. 



06 Colic 

Intestinal Colic. — 

Differential diagnosis from urinary colic, from hunger and 
from other pain. 

Not necessarily attended with passage of urinary sedi- 
ment, distended bowel and green stool common. 

Treatment: heat to abdomen, hot drinks, carminatives, 
enemas, castor oil, calomel, change of feeding. 

LIVER. 
Size. 

Infection. — From umbilical vessels, syphilis. 

Icterus. — 

Causes: infection of duct from (a) umbilical vessels, and 

(&) intestines. 
Congenital closure of duct. 
Symptoms: color skin and mucous membranes, color 

stools, fever, intoxication. 
Treatment: same as gastroenteric infection. 

URINARY SYSTEM. 

Uric Acid Deposit. — "Brick Dust." 
Cause of urinary colic. 

Anuria. — 
Frequency. 
Duration. 

Symptoms or results: intoxication, fever, irregular respi- 
ration, convulsions. 
Treatment: baths, water by mouth and enemata. 

GENITAL SYSTEM. 

1. MALE. 

Cryptorchidisms. — Undescended testicle. 
Always note, no immediate treatment. 

Adherent Prepuce. — 

Results, retained smegma may be irritating and later 
cause trouble. 

Management: retract if possible, split prepuce or circum- 
cise if necessary, dressing, after treatment, when done. 

2. FEMALE. 

Infection. — 

Catarrhal: common, due to handling, bathing, dressings, 
etc. 



68 Birth Injuries 

Colon bacillus: may ascend to bladder and thence to kid- 
ney and cause pyelitis that may become chronic. 
Gonorrheal: diagnosis. 
Treatment: keep clean. 

Menstruation. — True and false, not uncommon nor impor- 
tant. 

BREASTS. 

Functional activity in both sexes. 

Management, let alone. 

Mastitis or infection, cause, interference. 

INJURIES. 

Head.— 

Spontaneous and operative labors. 

Molding, caput seccedaneum, cephalhematoma. 

Marks on skin from pelvic bones and from instruments. 

Fractures and depressions of skull. 

Cerebral hemorrhage. 

Injuries to eye. 

Paralysis and paresis. 

Upper Extremities. — 
Fracture of clavicle. 
Fracture of humerus. 
Birth paralysis. 
Dislocations. 

Lower Extremities. — 
Fracture of thigh. 

MALFORMATIONS, DEFORMITIES (monsters). 
For classification see pages 86-90. 
Management of spina bifida, hare lip, cleft palate, etc. 

ANTENATAL INFECTIONS. 

Acute. — Variola, measles, scarlet fever, typhoid fever, ery- 
sipelas, cholera, malarial fever. 

Chronic. — Tuberculosis, rare; syphilis. 

HEMORRHAGIC AFFECTIONS. 

Umbilical Hemorrhage. — Time of occurrence, cause, treat- 
ment. 

Gastro-Intestinal Hemorrhage, Melena. — Cause, treatment. 



70 Premature Infants 

TEMPERATURE. 

At birth. 

Rapid decrease on account of large surface. 

Bearing on feeding and dressing. 

WEIGHT. 

Scales, importance of accurate weighing. 
Average, lessened, increased. 
Importance of frequent (daily) determination. 
First loss, rate of gain. 

PREMATURE INFANTS. 

Definition. — 

Uncertainty of fetal age, therefore use weight and length, 
length less than 48 cm. or weight under 2,500 gm. 
(5% pounds). 

Dangers. — 

1. Chilling. 

Rectal temperature 32° C. (90° F.) or below is very 
dangerous, also great danger when temperature is 
below 33.5° C. (93° F.). 

Budin found 28 per cent, of all premature infants with 
a temperature below 33.5 degrees C. Relation of sur- 
face of body to weight is relatively much greater in 
infants than in adults and still greater in premature 
infants. In adults about 260 2 cm. to 1 kg.; in infants 
600 2 cm. to 1 kg. 

Also less fat on premature infants, hence great and 
rapid radiation of heat. 

2. Starving. 

Digestive system not well developed, too little food and 
baby starves, too much food and digestive disturb- 
ances arise. 

Amount required from second to tenth day increases 
from about 100 gm. to 400 gm. 

Amount after tenth day, about one -sixth the weight of 
child. 

Mother's milk very necessary, give with spoon, dropper 
or by gavage if child cannot nurse. 

Frequency depends on amount taken each time. 

Management. — 
Incubator. — Substitutes. 

History, Winckel. Tarnier, Auvard. 

Construction. 



72 Bathing 

Heating: hot water tank. 
Air supply : from room or from outside. 
Course and rapidity of current. 
Index of air circulation. 
Moisture. 

Temperature 92 to 80 degrees — temperature of the child 
and its condition, sweating, etc., determines temperature 
of incubator. 
Oxygen: how given, for cyanosis. 

Feeding: may remove from incubator, care for regurgitation. 
Bathing: temperature of room 90 to 100 degrees, of bath 
98 to 103 degrees according to the temperature of child. 
Dressing: napkins, gown. 
Removal from incubator: gradual, depends on weight and 

condition. 
Subsequent history: good if cared for. 

INCUBATOR FOR OTHER DEBILITATED CONDITIONS. 

Weak, sickly infants at term or later can often be treated 
with advantage in the incubator. 

FURTHER MANAGEMENT 
BATH. 

Outfit: tub of enamel ware, painted tin, papier inache or 
rubber cloth, thermometer, wash cloths, soap, oil, towel. 

Table or bench: stand or sit. 

Temperature: of room 85 degrees, of water 98 to 100 
degrees. 

Method: wash and dry face, soap body, wash and dry, 
powder ( ? ) . 

Time: morning or night. 

Frequency : once or twice a day. 

CLEANING. 

Outfit. — Stand with wash bowl and pitcher, soap, cotton or 
gauze sponges, towels, napkins, pins, waste bowl or jar, 
rubber sheet. 

Table for Baby. — This table may contain the outfit or baby 
may be laid across the bed with the outfit on a movable 
stand within reach of the nurse. Baby should never be 
changed in the lap. 

Method. — Have good light, flex limbs, wash perfectly clean 
and dry perfectly, powder not necessary. 



DRESS. 

Objects.— Warmth, freedom, objection to pinning- blankets, 
short sleeves, etc., no difference between night and day. 

Outfit. — Safety pins: dozen large, medium and small; 
diapers, 4 dozen; shirts, 4 to 6, silk and wool, or cotton 
and wool; stockings, 4 to 6 pairs; gowns, 0; slips; 
jackets. 2; shoulder blankets, 2; bibs, cloaks, hoods, 
etc. 

SLEEP. 

Amount: three-fourths of the time. 

Bed: basket or crib. 

Mattress: blankets, sheets, pillows (?), hot water bag. 

FEEDING. 

Mother's Milk. — 

1. First few days. 
Colostrum, nature's food. 

Amount, 30 to 300 c.c. or 1 to 10 ounces per day. 
Frequency of nursing, every three to six hours if any 

secretion present. 
Length of nursing, not more than ten minutes at each 

breast. 

2. After establishment of milk secretion. 

Amount: one-fifth to one-tenth of baby's weight, 500 to 
750 c.c, 16 to 24 ounces per day, found by weighing 
baby before and after nursing. 

Frequency of nursing: seven to ten times per day, every 
two to three hours by day, depends upon amount and 
quality of milk obtained at each nursing. 

Importance of regular feeding. 

Length of nursing: ten to twenty minutes, one or both 
breasts. 

Index of feeding, weight of baby. 

Accessory feeding: water, 1 to 4 drams every one to 
three hours, salt solution enemas. 

Wet Nurse. — 

Much the best substitute for mother's milk, for she fur- 
nishes food fresh and clean that contains proper ingre- 
dients and vital ferments. 

Supply, hospitals, dispensaries. 

Directory of wet nurses necessary. 

Examination, for tuberculosis and syphilis, supply of milk 
and condition of breast, condition of her own child. 



6 Feeding 

Care, diet, exercise, work, bathing, bowels, management. 

Artificial Feeding. — 

Temporary, when the establishment of the breast secre- 
tion is slow or when the breast is tender or infected. 

Permanent, when secretion fails or condition of mother 
prevents nursing and no wet nurse can be obtained. 

Kinds: milk and artificial foods. 

Milk feeding. 

Composition of mother's and cow's milk (certified milk). 

Proteids. Sugar. Fat. 

Mother's 1 to 2 per cent. 6 per cent. 3 to 4 per cent. 

Cow's 4 per cent. 4 per cent. 4 per cent. 

Cream 4 per cent. 4 per cent. 16 per cent. 

Modification of cow's milk. 

Any composition may be made with milk, cream, sugar 

and water. 
For young infant. 

One ounce 16 per cent, cream, 4 ounces water, one tea- 
spoonful sugar. 
Objections to milk feeding. 
Lack of milk ferments (Escherich). 

Contaminated with germs. 
Essentials of good milk supply. 

Healthy clean cows, clean milking, clean receptacle , 
immediate cooling, careful transportation and distri- 
bution, careful use in house, keep cool. 

Feed with spoon or bottle. 

Care of bottle and nipple. 
Sterilizing and Pasteurizing. 

Objections: kills living germs but not toxins already 
formed. 

Destroys natural milk ferments. 

Necessity, when clean milk cannot be obtained. 



CHAPTER V 
ABNORMAL PREGNANCY 



DISEASES OF DECIDUA AND FETAL ADXEXA 

D. 5U-565; E. 177-226; H. 293-332; W. 586-61.',. 

DISEASES OF DECIDUA. 

Acute Infection of the Endometrium. — Exanthematous decid- 
uitis, measles, scarlet fever, etc., hematogenous or 
ascending, results generally in abortion or premature 
labor. 

Hemorrhagic deciduitis, cholera. 

Purulent deciduitis, gonorrheal, traumatic (attempts at 
abortion ) . 

Chronic Infection of the Endometrium. — 

Tuberculous deciduitis, maternal or fetal origin. 
Syphilitic deciduitis, maternal or fetal origin, pathological 
anatomy, effects, treatment. 

Hyperplasia Endometrii. — Glandular and interstitial endo- 
metritis, diffuse and localized, polypoid, cystic. 
Symptoms: abortion, hydrorrhea. 

Hypoplasia Endometrii. 

Results: abortion, cervical pregnancy (?). 

Hydrorrhea Gravidarum. — Decidual, rare, proven to occur, 
early or late, amount not generally very great ( 100 c.c.) . 

Amniotic, more common, generally late, amount may be 
great. 

Rupture, high and low; result, generally labor. 

Treatment, absolute rest. 

DISEASES OF THE CHORION. 

Hydatid Mole. — Ends of villi changed into vesicles, minute 
up to 1 to 2 cm. in diameter. 

Anatomy, proliferation of syncytium, not mucoid degener- 
ation of stroma, stroma changed and vessels disappear. 

Symptoms, rapid growth, soft uterus, hemorrhage. 

Frequency, 1 to 2,400. 



80 Placenta Previa 

Prognosis, danger from hemorrhage, perforation, uterine 

infection. 
Treatment, dilate uterus, remove, watch for chorioepithe- 

lioma. (Nature and cause of chorioepithelioma.) 

Chorioepithelioma. — History of discovery, Saenger, Marc-hand. 

Pathological Anatomy. — Chorionic elements, malignant 
growth, metastases in uterus, vagina, vulva, para- 
metrium, liver, lungs, etc. 

Symptoms, hemorrhage, tumor. 

Diagnosis, microscopic findings, history. 

Treatment, hysterectomy, excision of tumor. 

ABNORMALITIES AND DISEASES OF THE PLACENTA. 

Anomalies of Size. — Variation from the normal ratio of 
6 to 1, atrophy, hypertrophy. 

ANOMALIES OF DEVELOPMENT. 

Placenta Membranacea. — Covers the entire egg. persistence 
of villi in the reflexa and no distinct serotina, thin, 
decidua thin, generally previa, nutrition of ovum 
impaired, adherent to uterus, manual removal frequently 
necessary, danger of sepsis. 

Placenta Succenturiata and Spuria. — Origin from reflexa, 
vera or from the serotina and separated from the main 
placenta, frequency 1 to 2 per cent., danger, retention, 
hemorrhage, infection. 

Placenta Fenestra. — Cause. 

Multiple Placentas with Single Egg. — Duplex and bipartite, 
triplex and tripartite, etc. 

Placenta Circum valla ta. — Description, origin. 

Adherent Placenta. — Rare, 1 in about 200, different from 
retained placenta. Treatment given later. 

PLACENTA PREVIA. 

History.— Portal 1685, Barnes 1847, Hofmeier 1888. 

Definition. — 

Location in lower uterine segment or danger zone of 

Barnes (within 76 mm. of internal os). 
Complete or total and incomplete or partial. 
Central, marginal, lateral. 
Hemorhage "unavoidable" present. 

Frequency. — 1 to 5 per mille, complete central rare, lateral 
implantation without hemorrhage much more common. 



82 Ablatio Placenta 

Pathogenesis — 

1. Low implantation, a. Upper part of uterus not in con- 
dition for implantation (endometritis). b. Egg reaches 
fundus too early. 

2. Unusual cleavage of decidua vera downwards. 

3. Persistence and development of decidua reflexa which 
unites with decidua vera. 

Etiology. — Endometritis, multiparity. 

Pathological Anatomy. — Placenta thin, large, degenerated. 

Symptoms. — 

Hemorrhage, antepartum frequently without apparent 
cause and intrapartum, how produced, sudden, quantity. 
Postpartum hemorrhage. 

Diagnosis. — 

Hemorrhage, interference with presentation, palpation 
findings, uterine bruit over lower part of the. uterus. 

Differential diagnosis from abortion, separation of normal 
placenta, cancer of the cervix, rupture of placental Aes- 
sels (velamentous insertion of cord). 

Prognosis. — 

Maternal mortality, due to hemorrhage and sepsis, for- 
merly 25 to 40 per cent., now about 5 to 10 per cent., 
influence of location of placenta and method of treat- 
ment. 

Fetal mortality, 33 to 80 per cent., frequently premature, 
influenced by treatment. 

Treatment. — Considered under dystocia. 

INJURIES OF THE PLACENTA. 

Ablatio Placentae. — Rare, about 400 cases collected by 
Goodell and Holmes, generally occurs in later months of 
pregnancy, earlier separation leading to abortion more 
common. 

Causes, traumatism, nephritis, decidual or placental 
disease. 

Concealed and external hemorrhage. Concealed hemor- 
rhage: behind middle of placenta, retained by mem- 
branes, into amniotic sac, retained by head. 

Treatment, under labor complications. 

DISEASES OF THE PLACENTA. 

Acute Placentitis. — In acute infection of the endometrium, 
gonorrheal, septic, etc. 



S4 Hydramxiox 

Placental Tuberculosis. — Rare. 

Placental Syphilis. — Endarteritis of vessels in villi, small 
cell infiltration of stroma, villi become thick and degen- 
erate, placenta enlarged, frequently one- fourth weight of 
child instead of one-sixth. 

Placental Infarcts. — (Fibro-fatty degeneration of villi). 

Size, varying, minute, 1 to 2 cm., whole cotyledon, part of 
placenta. 

Frequency, small infarcts constant. 

Cause, obliterating endarteritis of villi and vessels, degen- 
eration of epithelium, fibrin formation, when several 
villi involved all become enclosed in fibrin wall, final 
degeneration of all structures. 

Results, when small or few no result, when more numerous 
growth of fetus may suffer. 

Treatment, none. 

Placenta Marginata.— Description. 

Placental Hematoma. — (Red infarcts). 
Cause not well known. 
Results yary with number and size. 

Calcareous Degeneration. — Not rare, cause not well known, 
results generally unimportant. 

Placental Cysts.— Frequency, size, location, origin: softening 
of infarcts, myxomatous degeneration. 

Placental Tumors. — Location on fetal surface. Myxoma 
fibrosum most common. 

DISEASES OF THE AMNION. 

Hydramnion. — Definition, 1 liter or more. 

Frequency, probably 5 per cent. 

Factors, monstrosities, twins, etc. 

Causes. — Amniotic, inflammatory condition. 

Fetal, obstructed circulation in cord or in heart, dimin- 
ished secretion from fetal kidney or skin. 

Maternal, disturbed circulation as in heart or kidney dis- 
ease or abnormal blood as in anemia or syphilis. 

Symptoms. — Acute form, rapid enlargement with pain 
from distention and from uterine contractions, pressure 
disturbances. Chronic form, edema, dyspnea, digestive 
disturbances, etc., resulting from pressure. 

Differential diagnosis: tumors, ascites, twins, mole preg- 
nancy. 



86 Diseases of Embryo and Fetus 

Prognosis, some danger to mother and more to child from 
dystocia, for example, weak pains, postpartum hemor- 
rhage and malpresentations, premature labor not uncom- 
mon. 

Treatment, prevent too early labor, combat heart or kid- 
ney disease or syphilis, allay pain, induce labor if 
necessary, watch labor. 

Oligohydramnion. — Lessened fetal secretion, rave. 
Effects, pressure on fetus, causing deformities. 

Amniotic Bands. — Origin, inflammation of amnion. 
Results, malformations, amputations, etc. 

Amniotic Cysts. — Origin. 
ABNORMALITIES AND DISEASES OF THE CORD. 
Marginal Insertion. — Battledore placenta. 

Velamentous Insertion. — Danger of rupture of vessels during 
labor. 

Stenosis. — Due to torsion, knots or to syphilitic or other 
disease of vessels. 

Abnormal Length. — Too long or too short apt to cause dys- 
tocia. See Dystocia. 

Tangling.— Results. 

Hernia in Cord. — Treatment. 

ABNORMALITIES AND DISEASES OF THE EMBRYO 
AND FETUS 

D. 535-5.',.',; E. 239-257; H. 332-357; W. 614-627. 

MALFORMATIONS AND MONSTROSITIES. 

Polysomatus terata. — Double and triple monsters. 

Originate generally in the germinal period, pathology of 
the germ, frequently cause dystocia. See page 136. 

I. Separate twins, omphalopagus or omphalosites. 

II. United twins— 

(a) Sy metrically united. 

1. Syncephalic or hyposchistos. 

2. Dicephalic or ephischistos. 

3. Thoracopagus or amphischistos. 
(&) Asymetrically united, parasites. 

1. Cephalo-parasitic. 

2. Prosopo-parasitic. 



8 Diseases of Embryo and Fetus 

3. Trachelo-parasitic. 

4. Thoraco-parasitic. 

5. Castro-parasitic. 

6. Lecano-parasitic. 

7. Melomelic. 

III. Triplets, quadruplets,, etc. 
(a) Separate. 
(6) United. 

Monosomatus terata. — Single monsters. 

Originate generally in the embryonic period or period of 
organogenesis, pathology of the embryo. 

I. Pantosomatus — whole body affected. 

1. Microsomia — dwarfism. 

2. Macrasomia — giantism. 

3. Hemihypertrophy and hemiatrophy. 

II. Merosomatus — part of body affected. 

1. Microsomia and macrosomia of various parts, e. g.. 
macrodactyly. 

2. Anomalies of spinal column and contents. 
( a ) Iniencephalus. 

(6) Rachischisis. 

Spina bifida-genesis, failure of closure of medullary 
canal, overdistention, etc. 

Location, whole canal, holorachischisis, localized or 
merorachischisis. 

Varieties: spina bifida without sac or protrusion, 
(a) without a covering, (b) with a covering, 
occulta; spina bifida with sac, rachicele, meningo- 
cele, myelomeningocele, most common, myelocysto- 
cele or syringomyelocele. 

(c) Congenital spinal curvature, lordosis, kyphosis, 
scoliosis. 

(d) Other anomalies, spondylolysthesis, assimilations. 

3. Anomalies of cranium and contents. 

Anencephalus, most common. 

Cephalocele, subclassification like spina bifida. 

Hydrocephalus. 

4. Anomalies of face and sense organs. 
Facial fissures 

Hare lip, labium leporinum. 
Cleft palate, palatoschisis. 
Cyclops and other anomalies of the eyes. 



90 Diseases of Embryo and Fetus 

Anomalies of other sense organs. 

5. Anomalies of the neck, fistulas, clefts, cysts, cervical rib. 

6. Anomalies of the thorax and contents. 

Malformation of ribs. 
Malformation of the breast, polymastia. 
Congenital diaphragmatic hernia. 
Sternoschisis or fissure of the sternum. 
Sternal fissure with ectopia cordis. 
Malformations of the heart and vessels. 
Malformations of the lungs. 
Malformation of the thymus gland. 

7. Anomalies of the abdomen and pelvis and contents. 

Gastroschisis, congenital umbilical hemia. 

Malformation of bile ducts, icterus. 

Intestinal diverticula, Meckel's. 

Intestinal stenosis and atresia, pyloric stenosis, 

imperforate anus. 
Patent urachus. 

Anomalies of bladder, ectopia vesicae. 
Malformation of the kidneys. 
Malformation of genitals. 

Male. 

Female. 
Hermaphroditism. 

8. Anomalies of limbs. 

Sympodia. 

Monopodia. 

Amelus. 

Hemimelus. 

Phocomelus. 

Absence of fibula. 

Polydactyly. 

INFECTIOUS DISEASES. 
Acute: fetal. 

Variola, vaccinia, measles, scarlatina, erysipelas, typhoid. 
cholera, malaria, influenza, fetal sepsis, pneumonia, 
infections with streptococcus, staphylococcus, pneumo- 
coccus, bacillus coli, anthrax. 

Chronic: germinal, embryonic or fetal. 
Tuberculosis, syphilis. 



92 Pregnancy and Gynecological Affections 

POISONING. 

Drug, gas, chloroform, ether, coal gas, morphin, alcohol,. 

phosphorus, lead, mercury, nicotin. 
Metabolic: eclampsia, uremia. 

NUTRITIONAL DISEASES. 

Marasmus from starvation of mother, cancer, tuberculosis 

and other maternal diseases, also due to disturbed 

placental function, embryonic or fetal. 
Diseases of unknown origin. Diabetes, chorea, spastic 

spinal paralysis, Little's disease; nephritis, dropsy; 

elephantiasis, ichthyosis; chondrodystrophia fetalis. 

TRAUMATISMS. 

Congenital Fractures. — Influence of fetal disease, chondro- 
dystrophia fetalis. 

Congenital Luxations. — Hip joint most important, may be 
due to error in development, importance of diagnosis at 
birth. 

PREGNANCY COMPLICATED WITH GYNECOLOGICAL 
AFFECTIONS 

D. 398-^16, 51Jf-516, 521—533: E. 257-273; H. 857-399; 

W. 567-580. 

VAGINAL AFFECTIONS. 

Vaginitis. — Non-specific, may be profuse and irritating 
leucorrhea, cleanliness, antiseptic (carbolic) douches., 
swabbing, astringent and sedative powders or solutions. 
Gonorrheal, symptoms, diagnosis, treatment, silver solu- 
tion. 

UTERINE AFFECTIONS. 

Retrodisplacement. — Version and flexion. 

Origin, generally antegravidal condition which persists; 
sometimes arises during pregnancy when uterine sup- 
ports are too lax or weak to maintain the enlarged 
organ in place. 

Frequency, not found very often, because there is generally 
autoreposition. Pregnancy also less common because 
of pathological condition of uterus. 

Symptoms, pain, nausea, bladder symptoms, infection, 
abortion, depending upon size of incarcerated uterus. 

Treatment, replace, gradual method or with anesthetic. 

Prolapse. — Origin, generally an antegravidal condition. 



94 Pregnancy and Medical Disease 

Degree and complications, incomplete and complete, ulcer. 

hypertrophy of cervix, abortion common, danger of 

infection in labor. 
Treatment, replace, pessary, keep hips elevated. 

Antefixation. — Different operations, development of posterior 
wall, abortion, pain, bladder symptoms, dystocia. 

Cancer Cervix. — Influence on impregnation; effect on preg- 
nancy, abortion, infection, etc., effect of pregnancy, 
rapid growth, hemorrhage, danger of infection in 
delivery. 
Treatment. — First half, hysterectomy, abdominal or vag- 
inal; second half, wait for viability of child, cesarean 
section or Porro or total hysterectomy or vaginal cesar- 
ean section. 

Fibromyomas of Uterus. — Pregnancy more common with 
subserous varieties, frequently increase in growth, abor- 
tion common, may obstruct obstetrical canal, danger of 
hemorrhage in labor. 
Treatment. — Sometimes myomectomy or hysterectomy 
during pregnancy, generally labor spontaneous, rarely 
or never induction of abortion. 

OVARIAN TUMORS. 

Complications of pregnancy. Frequency, generally one- 
sided, twisting of pedicle, intracystic hemorrhage, rapid 
growth. 

Complications of labor and puerperium. Obstruct canal, 
rupture, twisting of pedicle and gangrene. 

Diagnosis in pregnancy and labor. 

Prognosis, depends on complication and treatment. 

Treatment, remove, no puncture or induction of abortion. 

PREGNANCY COMPLICATED WITH MEDICAL DISEASES 

D. $76-507; E. 300-327; H. $01-1,31; W. $89—31$. 

CIRCULATORY SYSTEM. 

Heart Disease. — Due to pregnancy, endocarditis from infec- 
tion, myocarditis from toxemia or eclampsia, etc. 
Pre-existing disease does not prevent pregnancy. 

Frequency, 1 to 2 per cent. ; all myocardial and endocardial 
affections considered together. 

Effect on pregnancy, cause abortion; effects of pregnancy, 
dyspnea, bronchitis, edema, palpitation, indigestion, 
circulatory disturbances; effect of labor, sometimes 
sudden death; effect of puerperium, danger, immediate 
and later. 



96 Pregnancy and Medical Disease 

Prognosis varies. Complete control of patient necessary 
during pregnancy. 

Management. — "No marriage, no pregnancy, no nursing," 
applies only to grave cases. Prohibition of marriage is 
absolute. Prohibition of pregnancy brings up the ques- 
tion of sterilization (necessity for a written contract). 
Nursing often possible. Question of induction of abor- 
tion and premature labor. Always consultation and in 
induction of abortion a written contract. (See page 150.) 
Prevention of abortion and of the danger of pregnancy: 
spontaneous abortion occurs in about one-fourth of all 
pregnancies. Rest, diet, hygiene including exercise, sleep, 
dress, bathing, avoidance of infection. Induction of 
premature labor; methods, preparations. 

Labor, rapid delivery is important; operation, anesthetic, 
oxygen, third stage. 

Hemophilia. — Inherited and acquired. Treatment, calcium 
chlorid. 

Varices. — Legs, vulva, etc. Danger from rupture. Treat- 
ment, rest, bandage, collodion dressing. 

RESPIRATORY SYSTEM. 

Pulmonary Tuberculosis. — Frequency, few statistics, one in 
eighty. 

Effect on pregnancy, sometimes but rarely causes abortion. 

Effect of pregnancy generally increases disease, but occa- 
sionally nutrition is improved and the process checked 
to increase in the puerperium. prognosis bad, tubercular 
infection of child ( ? ) . 

Management. — Good feeding, fresh air and avoidance of 
fatigue, the chief factors in the proper management of 
all cases of tuberculosis are also of chief importance 
here. Sanitarium care desirable in the majority of 
cases. Question of marriage, pregnancy, lactation. 

DIGESTIVE SYSTEM. 

Dental Caries. — Fear of dental work common. Teeth should 
be put in good condition early in pregnancy, temporary 
work if necessary. 

Indigestion. — Sour stomach common, soda, diet. 

Constipation. — Treatment, fruit, enemas, cascara sagrada. 
calomel. 

SKIN DISEASES. 

Pigmentation. — Location especially on face, no treatment. 

Pruritus and Pruritus Vulvae. — Treatment, diet, salves. 



98 Pregnancy and Medical Disease 

URINARY SYSTEM. 

Bright's Disease. — Serious, question of marriage, pregnancy 
and nursing. Frequent abortion. 
Management. — Control patient, diet, exercise, clothing. 
Induction of abortion and labor. 

Pyelonephritis. — Frequency. 

Cause. — C. B. infection, ascending, by penetration of intes- 
tine and ureter. 

Symptoms. — Sometimes absent, fever, chill, cystitis, tend- 
erness, swelling. 

Treatment. — Watch, position, drugs, operation (?). 

NERVOUS SYSTEM. 

Neuralgia. — Sciatica most common ( cramps ) . 

Neuritis. — Toxic origin. 
INFECTIOUS AND CONTAGIOUS DISEASES. 

Acute General Infections. — Small- pox, measles, scarlet fever. 

cholera, typhoid fever, influenza, erysipelas. 
Each may cause abortion, infection of child, septic puer- 

perium. 
Management, treat the disease and try to prevent abortion, 

never induce abortion. 

Gonorrhea. — Acute and chronic; effect on child; effect on 

puerperium. 
Manifestations, discharge, vegetations, granular vaginitis.. 

cervical gonorrhea, vulvo-vaginal abscess. 
Treatment, rest, horizontal position desirable, washes, 

tampon, suppositories, vaccines, removal of abscess. 

Syphilis. — a. Infection before conception, generally abortion, 
child diseased. 

b. Infection at time of conception, sometimes abortion, 
child diseased. 

c. Infection after conception, child may escape. 

d. Paternal infection ( Colles' law ) . 

Treatment of mother in different cases, nursing child, wet 
nurse. 

PREGNANCY COMPLICATED WITH SURGICAL 
AFFECTIONS 

B. 507-508; E. 352-353; H. .' f 31-.' f 32 ; TT. 512-518. 

Traumatisms. — Abortion may result. 

Surgical Infections. — Abscess, ulcers, etc., cure before labor 
if possible. 



100 Toxemia of Pbegnancy 

Hernia. — Inguinal and femoral generally cause no trouble. 

Appendicitis. — Operation, indicated as in the non-pregnant 
conditions, abscess causes special dangers. 



DISEASES DUE TO PREGNANCY 

TOXEMIA. 

Definition. — Toxemia of pregnancy is a term applied to 
describe and include a variety of pathological conditions 
arising during pregnancy, which probably are due to the 
presence in tlie body of the mother of chorionic elements 
or of harmful ovular metabolic products. It is generally 
held to include the eclamptogenic disease and also 
emesis and peripheral polyneuritis gravidarum as well 
as other less well defined pathological conditions of 
toxic origin. 

Sources of poison — 

(a) Nonessential 

1. Parasitic. 

Infection from air passages. 

Infection from intestinal canal; contributory factors, 
diet, constipation, lack of bile. 

Infection from mucous membrane of the uterus (endome- 
tritis ) . 

Infection from urinary tract; especially old infection. 

2. Metabolic: maternal, from metabolism in the body of 
the mother. 

(6) Essential or specific. 

1. Dislodged syncytial masses and particles of villi. 

2. Ovular metabolic products. 

(c) Contributory factors. 

1. Lack of destruction. By blood ferments, liver, thyroids,. 

etc. 

2. Lack of elimination. By kidney, on account of lesions 

and disturbances to circulation and pressure on 
ureters. 

By intestines, on account of lesions in mucous mem- 
brane, and also fermentation distention. 

By skin, on account of disturbances of circulation. 

Effects of Poison. — Increased sensitiveness of nervous system. 
Disturbed circulation: condition of shock, splanchnic con- 
gestion. 



102 Vomiting of Pregnancy 

Symptoms of Toxemia. — Malaise, dizziness, headache, nausea, 
vomiting, edema, increased blood-pressure, lowered vital- 
ity with diminished appetite and greater liability to 
infection. 

EMESIS. 

D. 3^3-353; E. 880-288; II. J, 02-.) 07 : W. 519-529. 

Definition. — Distinguish between emesis gravidarum and 
emesis in gravidis. All degrees from slight "morning 
sickness" to pernicious vomiting. Description of differ- 
ent degrees. Frequency. Time of occurrence. 

Pathological Anatomy. — Sometimes degenerative changes in 
the liver. These are pathogenic and primary. Secondary 
changes in the kidney, heart, muscles and eventually in 
the entire body occur later. 

Causes. — 1. Basis is increased sensitiveness of nerve centers 
due to gravidal toxemia or to splanchnic congestion or 
chronic shock of pregnancy. 

2. Associated factors are unstable nervous organization, 
including hysteria ( Kaltenbach's theory). 

3. Peripheral irritation: uterus, prolapse, retroversion or 
flexion, adhesions, endometritis, tumors, etc.; bowels, 
constipation; stomach, catarrh, yeast fermentation, 
displacement, dilatation; dress, corsets. 

Diagnosis. — Distinguish between emesis gravidarum and 
emesis in gravidis. Distinguish between cases with 
serious organic lesions and those with less organic 
trouble. 

Treatment. — Prevention: prevent toxemia, correct sources 
of peripheral irritation. 

Mild cases: correct toxemia by increasing elimination, 
improving circulation by use of horizontal position, hot 
drinks, etc. 

Hyperemesis, radical treatment early; bed; nursing; injec- 
tion of salt solution rectal (a) cleansing, (6) nutritive 
(addition of alcohol) ; injection of salt solution, subcu- 
taneous; lavage of stomach and stomach feeding; medi- 
cine, symptomatic; induction of abortion. 

NEURITIS GRAVIDARUM.— Symptoms, in legs and arms. 
Cause, toxemia. 

Frequency, quite common in mild form, generally unrecog- 
nized. 
Treatment, eliminant and symptomatic. 



104 Eclampsia 

ECLAMPTOGENIC TOXEMIA GRAVIDARUM. 

D. 3.53-371; E. 273-299; H. 6> f 6-660 ; TT. 532-567. 

Definition. — A specific disease of pregnancy, probably due 
to ovular poisons which produce distinct anatomical 
lesions and disturbances of function and cause a definite 
syndrome of symptoms, the most prominent of which is 
convulsions or eclampsia. 

Etiology. — Chorionic elements or ovular metabolic products, 
in excess and not broken down by blood ferments or 
by the liver, thyroid and other organs with katabolic 
functions. These substances injure the organs and tissues 
of the body, especially the eliminating kidney and the 
brain. Other theories. Halbertsma, Dienst, Zweifel. 
Stroganov. 

Contributing Factors. — Primaparity, 75 per cent, of all cases 
of eclampsia (as about 30 per cent, parae are priniiparae 
the frequency of eclampsia among primaparae is about 
5 per mille or one-two-hundredth, and among multip- 
arae, 0.7 per mille or one-fourteen-hundredth, i. e., 
about seven times as frequent in primiparae as in 
multiparae) . 

Twin pregnancies, 5 per cent, of all cases of eclampsia. 

Hydramnios, heredity, epidemic influence. 

Pathological Anatomy. — Liver, chorionic epiblast emboli, 
degeneration, necrotic areas, yellow atrophy, hemor- 
rhages. 

Kidney, constant lesions, increased weight and size, cloudy 
swelling, fatty degeneration of epithelium, hemorrhages; 
necrotic areas. 

Ureters, sometimes dilated. 

Brain, edema. 

Heart, almost constant degeneration of myocardium. 

Blood vessels, thrombosis, emboli. 

Placenta, generally retroplacental hemorrhages. 

Symptoms. — General edema, "occult." 
Increased blood-pressure. 

Albuminuria, casts, change in ammonia coefficient. 
Albuminuric retinitis, disturbance of vision. 
Xausea and vomiting, precordial disturbances. 
Xeuralgia, headache, dizziness, restlessness. 
Stupor, coma. 

Convulsions, eclampsia proper, description, nature, produc- 
tion, duration, sequelae, recurrence. 



106 Eclampsia 

Frequency. — 

Eclamptogenic toxemia about one in twenty or 5 per cent. 

Eclampsia about one in 500, two per mille, probably about 
120 a year in Chicago; therefore the eclamptogenic dis- 
ease is 25 times more common than eclampsia proper. 

Frequency of eclampsia in gravidis, intrapartum and in 
puerperis. 

Diagnosis. — 

Distinguish eclamptogenic toxemia from edema of lower 
extremities due to intra-abdominal pressure, from 
Bright's disease, from pyelonephritis, from valvular 
heart, disease with dyspnea and edema, from organic 
stomach, boAvel and liver disease, from emesis gravi- 
darum. 

Distinguish eclamptogenic convulsions from hysteria, 
epilepsy, apoplexj^, meningitis, uremic convulsions. 

Distinguish eclamptoge'nic coma from coma from other 
conditions. 

Prognosis — 

Eclamptogenic disease. Danger of convulsions about one 
in twenty-five. Danger of coma still less. Depends on 
severity and treatment. 
Eclamptogenic convulsions, mortality from 10 to 30 per 
cent. 

Treatment — 

Eclamptogenic toxemia: rest, complete or partial depend- 
ing on the severity of the case. 
Elimination, intestinal, by laxatives like calomel. 

salines, oil, etc., and enemata. 
Kidney by water, not efficient. 
Skin by sweats, also not efficient. 

Diet, water alone if condition urgent, milk, whey, etc., 
fresh fruits, cereals. 
Eclampsia: During attack protect patient, artificial respi- 
ration, oxygen, no anesthetic. During intervals, con- 
trol the attacks with morphin and chloral and eliminate. 
Venesection. Empty uterus if possible to do so without 
too much risk. See dystocia. 

ABORTION 

D. JtlG-hSl ; E. 326-3J t J,; H. J,32-.',J l H ; W. 627-6.',0. 

Definitions. — Abortion, miscarriage, premature labor, threat- 
ened, inevitable, partial, complete, missed, spontaneous, 
provoked, therapeutic, criminal. 



08 Abortion 

Frequency. — Twenty per cent, to 25 per cent., criminal very 
common. 

Pathological Anatomy. — (Condition of egg). 

First month, generally expelled entire with deeidua vera. 
Second month, entire with deeidua or only with deeidua 

reflexa, without reflexa or sometimes sac ruptures and 

ernbryo and membranes are expelled separately. 
Third month, sometimes entire. Later generally rupture 

of sac and expulsion in two stages. 
Embryo may be alive or dead. 
Embryo may have been dead some time and then it is 

small for the period of gestation or it may entirely 

disappear. 
Hemorrhages into walls of egg help form blood and flesh 

moles, also tuberous mole of Breus where the hemor 

rhage is into chorion, making folds of the amnion 

project. 

Causes. — Uterine contractions are always excited (when no 
contractions and dead fetus we have "missed" abortion). 
Sensitiveness of the uterus varies in different women. 
I. Spontaneous and unintentional abortion. 

a. Factors which directly and chiefly stimulate uterine 
contractions. 

Drugs, ergot, quinin, etc. 

Massage, electricity, vaginal douches. 

Acute (e. g., infectious) and chronic (e. g., syphilis) dis- 
eases. They are generally associated with local uterine 
diseases which are sequela; of general condition. 

Diseases of the endometrium and rest of the uterus (de- 
cidual diseases). 

Displacement of uterus, especially incarceration in retro- 
displacement. 

Distention of the uterus as in hydramnion and multiple 
pregnancy. 

b. Factors which chiefly tend to cause injury to or more 
or less separation of the egg. 

Traumatism, falls, blows, strains, placenta praevia. 

c. Death of fetus, which then acts as intrauterine stimu- 
lant. Due to obstruction of circulation in cord, dis- 
turbed placental function, placental detachment, syphilis 
of placenta, infection of placenta, infarct. 

d. Fetal disease, which may be due to infection, acute or 
chronic (syphilis), or which may be developmental. 



110 Criminal Auortiox 

II. Provoked abortion: Therapeutic or criminal. Oxy- 
tocic drugs, massage, electricity, vaginal injections, dila- 
tation of the cervix with sounds, tents, tampons, etc.; 
intrauterine injections, sounding, rupture of membranes, 
curettage. 

Symptoms.— Pain, especially in back, intermitting and 
constant. 
Hemorrhage, all grades. 

Dangers. — Hemorrhage, infection from operation and from 
discharge. 

Prophylaxis. — Care in work or exercise, travel, bathing, 
clothing, diet, sexual intercourse, correct uterine dis- 
placement, treat for syphilis. 

Treatment. — 

1. Threatened, (a) When no infection, bed, morphin. even 
when hemorrhage and dilatation of cervix. 

(b) When infection, empty uterus. 

2. Inevitable, question of diagnosis. 

(a) When no infection, may tampon vagina and cervix to 
increase dilatation of cervix and for hemorrhage. 

(b) When infection, empty uterus, generally curette 
under anesthetic, technic of operation important. 

CRIMINAL ABORTION. 

Frequency. — Great increase in all countries in recent times, 
international movement started in France. 

Reasons for Repression. — 

1. Injury to fetus which, like all human beings has the 
right to life. Immaturity and dependency does not 
change this right. Fetus is not a pars viscerum that 
the mother can treat as she likes. 

2. Injury to mother, unjustifiable risk to her health and 
life. Statistics collected by the French investigators of 
the international movement show enormous morbidity 
and mortality. 

3. Injury to relatives of fetus and mother, questions of 
inheritance may be involved, father's moral and legal 
rights in fetus. 

4. Injury to state, interested to prevent depopulation, 
morbidity of women and moral degeneration. 

Repressive Measures. — » 

Voluntary cooperation of citizens, churches, clubs, socie- 
ties, etc. Medical societies should take active interest. 



[12 Ectopic Pregnancy 

Laws, (a) Common law. Fetus not a being before quick- 
ening, therefore feticide before quickening no crime. 
Afterward a misdemeanor not punishable with impris- 
onment. 

(b) Statute laws. Differ in different states. Generally 
feticide, i. e., induction of abortion either before or after 
quickening is a high misdemeanor punishable by impris- 
onment but not considered murder. Consent of mother 
makes no difference. Intent is the essence of the crime. 
It is murder when death of the mother results. Publi- 
cation of abortionists' advertisements and sale of 
abortifacient drugs is equally a crime with operative 
manipulations. 

Execution of laws. Difficulty in obtaining evidence. Prac- 
tically no trials or convictions for simply inducing abor- 
tion and few trials even when murder, i. e., death of 
the mother, results. Coroner's inquest necessary in all 
cases.^ Then the case goes to the grand jury. The 
accused may be brought to the grand jury on sworn 
complaint if the coroner's jury fails to hold him. Impor- 
tance of correct reports of the fact of abortion includ- 
ing a positive diagnosis of pregnancy. Privileged com- 
munications not granted in Illinois. Dying declaration, 
the essential characteristics of which are abandonment 
' of hope and voluntariness is generally the most impor- 
tant part of the testimony. In it a definite person 
should be named. 

ECTOPIC PREGNANCY 

D. 381-398; E. SH-850 ; H. Wt-fal; W. 61,0-669. 

Definitions. — Extrauterine, tubal; interstitial, isthmial, 
ampullar; ovarian, abdominal (secondary), cornual. 
multiple and repeated pregnancies. 

Causes. — Delay of the egg in reaching the uterus from exter- 
nal migration of egg to opposite tube, disturbance in 
ciliary current, disturbances in tubal contraction which 
may be due to adhesions. 

Obstruction in tubes from tumors, bendings, depressions 
that may result from inflammatory adhesions, which 
permit passage of spermatozoa only but not the return 
of the fertilized ovum. 

Favorable grounds for nidation. 

Anatomical Changes. — Nidation, columnar or intercolumnar, 
decidua vera, serotina and reflexa, intervillous hemor- 
rhage, placenta. Development of muscular sac. 
Changes in uterus, growth, decidua. 



14 Ectopic Pbegnaxcy 

Penetration or rupture of tubal wall with hemorrhage (a) 
into abdominal cavity and formation of hematocele, 
generally retrouterine, that may be encapsulated by 
adhesions to surrounding organs and later, if not 
absorbed, become infected, (b) in broad ligament. 

Tubal abortion, incomplete and complete with formation 
of a tubal mole. 

When continued life of fetus, adhesions to abdominal 
organs, eventual death of fetus, maceration, absorption, 
suppuration, lithopedion formation. 

Symptoms. — Local pain, tumor, uterine hemorrhage, shock. 

Diagnosis. — Differential. 

Early ectopic from abortion, extrauterine tumor, sacto- 

salpinx. 
Late ectopic, child under abdominal Avail. 

Treatment. — Before rupture, prevent tubal abortion or rup- 
ture of tube by quiet until diagnosis is made, then 
remove by abdominal or vaginal laparotomy. 

During hemorrhage, immediate operation when possible, 
otherwise absolute quiet and morphin till patient can 
be moved. 

After cessation of hemorrhage and death of embryo or 
fetus expectant treatment, unless infection or other 
symptoms; then vaginal drainage. 

STERILITY 

Frequency. — One-eighth of all marriages, 40 per cent. male. 

a. Male, aspermatism, aspermatozoa (stricture, etc.), 
malformation. 

b. Female. First — Lack of ovulation; congenital, acquired 
defect. Second — Lack of fertilization: destruction of 
spermatozoa, obstruction to passage of sperm, malfor- 
mation, stricture, discharge. Third — Destruction of 
fertile ovum: failure of implantation, failure of prepa- 
ration of uterus. 



CHAPTER VI— ABNORMAL LABOR 



ABNORMALITIES IN MECHANISM AND MECHANISM IN 
ABNORMAL PRESENTATIONS 

D. 576-626; E. 480-533; H. 259-290; W. 282-300, 821-829. 

VARIATION IN MECHANISM IN SKULL PRESENTATION. 

In First Step.— 
. I. Interference with descent. 
a. Contracted pelvis. 

1. Flat pelvis, deflexion and parietal bone presentation 
common. 

2. Generally contracted pelvis, extreme flexion at inlet. 
6. Tumor: ovarian, uterine, etc. 

c. Enlarged head. 

d. Bad attitude or presentation. 

1. Deflection: brow, face. 

2. Inclination: anterior parietal, posterior parietal. 

e. Lack of dilation of cervix. 
LL Inefficient forces. 

In Second Step. — 

I. Deep arrest. 

a. Failure to flex. 1. Inefficient force. 2. Shape of head. 

3. Lax pelvic floor. 4. Tumor of neck. 

b. Failure to rotate. 1. Inefficient force. 2. Lack of 
flexion. 

II. Posterior rotation. — Occiput posterior. 

Causes: deflexed attitude, more frequent with small head, 
also failure of body to rotate. 

Frequency: 5 to 10 per cent, of o. p. positions, therefore 1 
to 3 per cent, all cases. 

Prognosis: longer labor, greater danger of tear of peri- 
neum. 

Mechanism of third step in o. p. position. 

1. Bregma presses against the border of the symphysis 
pubis, occiput rotates over perineum, face passes under 
pubes. 

2. Glabella passes border of symphysis, brow appears., 
occiput rotates over perineum, face escapes. 



118 Mechanism of Abnobmal Labor 

In Third Step. — 

a. Contraction of iscliiospinal strait. 
6. Obstruction of coccyx ( ankylosis ) . 

c. Contraction of diameter between ischial tuberosities 
(funnel pelvis). 

d. Lack of dilatation of vagina and vulva (cicatricial). 

In Fourth Step.— 

Over rotation of head. 

Interference in delivery of shoulders. 

Failure to rotate. 

Failure of anterior shoulder to pass under symphysis. 

Excessive size of shoulders (in monsters). 

MECHANISM IN FACE PRESENTATION. 
Causes of Presentation — 
Primary: before labor, rare. 

Secondary: dolicocephalus, obliquity of uterus, contracted 
inlet, occiput is long arm of lever. 

Diagnosis. — 

External examination. Shape of trunk, heart tones heard 

through chest. 
Internal examination, after rupture of membranes. 

First Step- 
Long duration, molding of head, unusually great distance 
of advanced part from plane of largest circumference. 

Second Step.— 

Similar to skull presentations, chin anterior. 

Posterior rotation of chin makes labor almost impossible. 

Third Step.— 

Chin passes under pubes, occiput rolls over perineum, exit 
in s. m. o. circumference. 

MECHANISM IN BROW PRESENTATION. 

Rare, generally temporary, passing into face or occiput; 
when persistent, characteristic molding, glabella passes 
under pubes, occiput escapes, then face. 

MECHANISM IN BREECH PRESENTATION. 

First Step. — Bitrochanteric diameter in oblique diameter of 
pelvis. Frequently slow progress on account of slow 
dilatation of cervix. 

Second Step. — Rotation, back lateral, common but not abso- 
lutely necessary. 



120 Dystocia 

Third Step. — Lateral flexion or inclination of breech on 
body, anterior hip under pubes, posterior hip over peri- 
neum, descent and rotation of arms and shoulders, 
expulsion of chest. 
Variation: displacement of arms. 

Fourth Step. — Descent of head, internal rotation of head : 
expulsion of face, brow, vertex, occiput. 

Variation: rotation occiput posterior. 

Dangers during fourth stage: when delay, from compres- 
sion of cord, partial separation of placenta, etc. 

MECHANISM IN CROSS PRESENTATION. 

Spontaneous evolution, spontaneous version, conduplica- 
tion, all rare. 

DYSTOCIA 

Due to abnormalities in: 1, forces; 2, passages; 3, pas- 
senger; 4. to accidents. 
Definition. 

Pathological Forces 

D. 567-579; E. 545-552; E. 471-476; W. 67 5-6S4. 
rATHOLOGICAL UTERIXE COXTRACTIOXS. 
I. EXCESSIVE. 
General. — 

Increase in intensity, duration (tetanic), frequency. 
Occur at beginning of labor or during labor. 

Irregular. — 

The most important irregular contractions are those which 
involve the junction of the contracting and dilating 
zones or the ring of Bandl and cause the "hour-glass" 
contraction of the uterus. This spasm or stricture 
occurs after there has been previous dilatation and the 
head has passed through the ring. It is diagnosed by 
the groove in the uterus felt through the abdominal 
wall, interference with labor and by internal examina- 
tion. It is best treated by sedatives or when necessary 
by vaginal cesarean section. 

Causes. — a. Increased irritability of uterus, b. Premature 
rupture of membranes, c. Obstructions to expulsion of 
child, for example, contracted pelves, bad presentation, 
etc. d. Operative interference, e. Ergot. 

Results. — a. Increased pain, pain not always index of con- 
tractions. 
b. Precipitate labor, distinguished from painless labor. 



122 Contracted Pelves 

c. Rupture of uterus. 

<J. Asphyxia of child from compression of placenta and 
uterine vessels. 

Treatment. — Morphin, codein, chloral, seopolamin, ether. 

II. WEAK. Uterine inertia or atony. 

Decrease in intensity, duration or frequency. 

Primary at beginning of labor or secondary during labor. 

Causes. — a. Congenital weakness of uterine muscles. 6. 
Acquired weakness due to general disease as tuberculo- 
sis, etc. c. Fibroids, d. Metritis, e. Dilatation of uterus 
from hydramnion, twins, etc. /. Exhaustion due to 
tough membranes, contracted pelves, resistant cervix or 
perineum, etc. 

Results. — Exhaustion, infection, danger to child. 

Treatment. — Morphin, chloral, ether, etc. 
Pituitary extract or ergot with great care. 
Empty bladder and rectum. 
Massage. 

Rupture membranes. 
Dilate cervix. 
Deliver child. 
Care for hemorrhage in third stage. 

PATHOLOGICAL ABDOMINAL CONTRACTIONS. 

Inefficient, causes, generally pain or fear. 
Treatment, ether, management. 

Dystocia Due to Pathological Conditions of the Passages 

D. 6U-725; E. 579-650; H. £77-572 J W. 6SJf-S15. 
DEFORMED OR CONTRACTED PELT IS. 

History.— Deventer, f 1724; Smellie, f 1763; Baudeloque, 
t 1813; Michaelis, f 1848, and Litzmann, f 1885. 

Definition. — P. p. m. 10 cm. or under, operative delivery not 
always necessary, not even dystocia. 
Contraction generally in inlet, may be in excavation, in 
straits or bony outlet. 

Classification. — 

I. By shape, generally contracted, flat, obliquely, trans- 

versely, irregularly contracted, funnel shaped. 

II. Bayer's. 

a. Primary, due to disturbances in antenatal or postnatal 
development. 



124 Contracted Pelves 

1. Split. 2. Assimilation. 3. Naegele. 4. Robert. 5. 
Dwarf. 6. Infantile. 7. Generally contracted. 8. Sim- 
ple flat and irregularly contracted. 9. Simple funnel 
pelvis. 

5. Secondary. 

a. Due to pelvic disturbances. 

1. Rachitis. 2. Osteomalacia. 3. Osteitis. 4. Trauma. 
5. Tumors. 

b. Due to anomalies in other parts of the skeleton. 

1. Scoliosis. 2. Kyphosis. 3. Lordosis. 4. Kyphoscolio- 
sis. 5. Spondylolisthesis. 6. Defects of lower extremi- 
ties (one sided or both sided), congenital hip disloca- 
tion. 

Examination and Measurement. — 

External: sp., cr., tr„ B., oblique, post. sup. sp., depth of 

symphysis, tuberosities. 
Internal: p. p. i., p. p. m., ischial spines. 
Relation: p. p. i. to p. p. m. 
Methods: pelvimeter, tape, finger. 

Frequency. — 

Five to 20 per cent. In Chicago each year labors in 6,000 
to 10,000 contracted pelves, dystocia in about 25 per 
cent, of all contracted pelves; therefore 1,500 to 2,500 
cases of dystocia from this cause each year in Chicago. 

Forty to 90 per cent, due to rickets. 

Idiopathic flat, in 5 to 40 per cent. 

Idiopathic generally contracted, 5 to 40 per cent. 

RICKETS IN GENERAL. 

Nature. — Disease of the developing bone. 

First stage. Congestion especially of the juxtaepiphyseal 
and subperiosteal layers. 

Second. Softening or decalcification with production of 
deformity. 

Third. Cure or hypercalcification with fixing of deformi- 
ties. 

Etiology.— Specific cause unknown. 

Influence of malnutrition, disease as tuberculosis, etc., 
gastroenteritis, climate, race. 

When Active. — In infancy, in utero ( ? ) . 

Bones Affected.— Long bones, flat bones, chest and pelvis 
most common. 



126 COXTBACTED PELVES 

Frequency. — Nearly identical with frequency of contracted 
pelves, that is, about 10 per cent, of all children, more 
important in girls. 

Early Diagnosis. — Careful examination of naked child, bead- 
ing of ribs, deformity of chest and head. 

Treatment of Active Rickets. — Horizontal position, good 
feeding, care of gastroenteritis, cod-liver oil. 

RACHITIC PELVIS. 

Chief Factors in Causing Deformity. — 

1. Softening of bone. 

2. Weight of trunk and traction of ligaments and muscles. 

3. Arrest of development of bone. 
Changes in Sacrum. — 

Rotation, promontory pushed downward and forward and 

lower part backward. 
Sacro sciatic ligaments generally pull the end forward and 

cause sharp lower concavity. 
Sometimes upper sacral vertebra is pushed forward and 

causes second or false promontory. 
Sometimes entire sacrum is pushed forward, decreasing 

anteroposterior diameter of excavation and causing a 

transverse convexity. 

Changes in the Hip Bones.— 

Rotation pf the wings of the ilia. 

Change of the curve in the linea innominata. 

Change in the position of the acetabula. 

Change in the tuberosities. 
Influence of Etiological Factors. — 

In flat rachitic pelves there has been no arrest in the 
development and there is only change in form but not 
in the size of the pelves. 

In flat generally contracted rachitic pelves there has been 
arrest of development. 

In generally contracted rachitic pelves there has been 
arrest of development with comparatively little change 
in form. 

In irregular contracted or pseudomalacic rachitic pelves the 
child walked during the period of softening. 
Clinical Diagnosis. — 

Anamnesis: History of infantile disease, walking, cutting 
of teeth. History of dystocia in previous labors. Deflex- 
ion or parietal presentation or prolapse of cord indicates 
flat pelvis while extreme flexion at the inlet is sign of 
generally contracted pelvis. 



128 Contracted Pelves 

General examination, head, ribs, clavicles, upper extremi- 
ties, lower extremities. 
Pelvic examination. 
Inspection and palpation. 
Mensuration, sp., cr., tr., B., p. p. i., p. p. m. 

PELVES CONTRACTED IN THE INLET. 
Spontaneous Labor. — ■ 

Possible on account of molding of the head. 
Shape of head and marks on the head. 
Asynclitism common. 

Management. — 
Classification. 

1. P. p. m. 7 to 10 cm. 

2. P. p. m. 6 to 7 cm. 

3. P. p. m. to 6 cm. 

Third class. Conservative cesarean section where no infec- 
tion or contamination, Porro or total hysterectomy 
where infection. 

Question of sterilization with conservative cesarean sec- 
tion. 

Induced abortion. 

Second class. Same as third except craniotomy on dead 
or dying child. 

First class. Primipara: usually wait for spontaneous 
labor or term. Expression, high forceps, symphysiotomy 
or hebosteotomy, cesarean section, Porro. 

Multipara: induce premature labor, diet. 

OSTEOMALACIC PELVIS. 

Osteomalacia in General. 

Nature. — Disease of adult life, much more frequent in 
women, especially in pregnancy and puerperium, affects 
most the pelvis, thorax, spine, cranium, decalcification, 
increase in osteoid tissue. 

Symptoms. — Rheumatoid pain, progressive inability to walk. 

Pathogenesis. — Theories in malnutrition, ovarian stimula- 
tion disturbances. 

Frequency. — Rare except in regions in Germany, Switzerland 
and Austria. 

Osteomalacia as an Oostetric Complication. 



130 Contracted Pelves 

Pelvic Changes. — Due to -weight of trunk and pressure of 
femurs. Sacrum pressed forward and sides of pelvis 
pressed in. 
Angle of rami much lessened. 

Treatment. — Castration, to stop progress of disease. 

If contraction great, cesarean section or Porro with 
castration. 

KYPHOTIC PELVIS, FUNNEL PELVIS. 

How Produced. — Effect of trunk weight on sacrum, varia- 
tions depend on location of kyphosis. 

Nature of Deformity. — Shape and size of inlet, excavation, 
straits and outlet. 

Diagnosis. — Measurements of outlet important. 

Prognosis. — Maternal and fetal mortality. 

Treatment — 

In primiparse wait for spontaneous labor if transverse 
diameter of straits greater than 7 cm. Where inter- 
ference absolutely required, careful trial with forceps 
and, if necessary, symphysiotomy or hebosteotomy. 

In multiparas with history of dead child and bi. i. diameter 
less than 8 cm., cesarean section. When bi. i. less than 
7 cm., cesarean section. 

AFFECTIONS OF SOFT PARTS. 

OVARIAN TUMORS. 

When abdominal, may interfere with uterine contractions, 

cause dyspnea. 
When pelvic, prevent labor. 
Spontaneous labor in only three-fourths of all cases. 

Treatment — 

Before labor, remove; puncture or induction of labor or 

abortion not advisable. 
During labor, replace, rupture, incise, ovariotomy, cesarean 

section. 
During puerperium, danger from sloughing of tumor. 

HYDATID CYST. 

Treatment : puncture, incision. 

DISTENDED BLADDER. 

Causes, compression of urethra between head and sym- 
physis, disturbed innervation. 
Treatment: catheterization if necessary. 



132 Dystocia Due to Soft Parts 

DISTENDED RECTUM. Coprostasis. 

Treatment: mechanical emptying may be necessary. 

FIBROMYOMAS OF UTERUS. 

Site Above Cervix or Lower Uterine Segment. — Passage not 
obstructed unless tumor subperitoneal with long pedicle 
when it may descend into the pelvis. 

Site in Cervix or Lower Uterine Segment. — Spontaneous 
labor possible when, (a) tumor is small, (o) tumor 
descends out of pelvis, allowing child to pass, (c) tumor 
can ascend into abdomen. 

Treatment. — 

Wait when spontaneous labor is possible. 

Try to push up tumor. 

Excise the tumor through the vagina. 

Craniotomy on a dead child if obstruction not too great. 

Forceps ( ? ) , cesarean section, Porro. 

CANCER OF THE CERVIX. 
Dangers During Labor. — 

1. Hemorrhage. 

2. Infection. 

3. Obstruction of passage by prevention of dilatation of 
cervix. 

4. Deep tears. 

Treatment. — 

Remove cancer and make vaginal cesarean section, follow 
with hysterectomy. See complications of pregnancy. 

CONGLUTINATION OF EXTERNAL OS OF CERVIX. 

Origin. — 

Congenital, persistence of "pinhole os." 
Acquired, traumatic, from caustic applications, injuries of 
labor, operations. 

Diagnosis. — Distinguish from displaced os. 

Treatment. — Open with finger pressure, use retractors, find 
location, dilate or cut. 

RIGIDITY OF CERVIX. 

Causes. — Spasms, (retraction), structural undilatibility, 
cicatricial contraction. 

Results. — Depend somewhat upon persistence of membranes. 

Treatment. — Artificial dilatation. 



134 Dystocia Due to Soft Parts 

EDEMA OF CERVIX. 

General, anterior lip or posterior lip. 

Causes. 

Prevention. 

Treatment. 

DISPLACEMENT OF OS. 

Anterior or posterior or laterally, sometimes above inlet. 

Causes. — Displacement of uterus, adhesion of uterus, includ- 
ing vaginal and ventral fixation, sacculation of lower 
uterine segment. 

Diagnosis. — Vaginal examination, anesthetic if necessary, 
differentiate from conglutination and from complete 
dilatation. 

Results. — Prolonged labor, danger to child and mother. 

Treatment. — Manual correction of displacement, dilatation, 
incision, cesarean section. 

ADHESION OF MEMBRANES TO CERVIX. 

Prevents dilatation of cervix. 

Treatment, separate or rupture membranes. 

AFFECTIONS OF VAGINA. 

Congenital. Small vagina, double vagina, etc. 
Acquired. Stenosis from trauma. 
Functional. Spasmodic contraction of levator ani. 
Treatment. Anesthetic, forceps, incisions, cesarean section. 

AFFECTIONS OF VULVA. 

Resistent hymen. 
Traumatic stenosis. 
Resistent perineum. 
Treatment: incision, episiotomy. 

Pathologic Condition of Passengee 

D. 626-6-U; E. 480-545; H. 572-590; 
W. 813-821, 867-S69. 

EXCESSIVELY LARGE. 

Causes. — Large parents, especially father, prolonged preg- 
nancy. 

Diagnosis. — Muellers method, placenta enlarged and liquor 
amnii also increased and therefore symptoms of exces- 
sive distention. 



136 Dystocia Due to Soft Parts 

Treatment. — Forceps where necessary, perhaps symphysi- 
otomy or hebosteotomy or cesarean section. 

HYDROCEPHALUS. 

Frequency.— 1 in 300 to 1 in 3,000. 

Cause. — Not known. 

Pathological Anatomy. — Bones separated, sometimes de- 
formed, all liquids of brain and its membranes increased 
in amount, other deformities. 

Diagnosis. — Not often made during pregnancy, external and 
internal palpation, course of labor, in breech presenta- 
tion especially difficult. 

Prognosis. — Mortality high, due to failure in diagnosis and 
attempt at impossible operation. 

Treatment. — Perforation. 

HEAD LESS PLASTIC. 

Head may be increased in size or not. 
Increased ossification of sutures and fontanelles. 
Operative interference often necessary. 

PARCHMENT SKULL. 

Mechanism interfered with, operation may be necessary. 

LARGE SHOULDERS. 

With large heads, normal or small heads and with ace- 

phalic monsters. 
May prevent birth of head or not. 
Treatment, expression, traction, bring down arm, cleid- 

otomy in dead child or monster. 

OTHER AFFECTIONS OF BODY. 

Tumors, ascites, distended bladder. 
Treatment. 

MONSTERS. 

Single or double. 

MULTIPLE PREGNANCY. 

Simultaneous engagement (locked fetuses). 

PATHOLOGIC PRESENTATIONS AND MECHANISM. 

Due not only to passenger but to relation of passenger 
and passage. 



138 Dystocia Due to Soft Parts 

Includes sinciput, brow, face and parietal bone presenta- 
tion, o. p. rotation, deep transverse arrest, breech and 
transverse presentations with varieties and variations in 
mechanism and compound presentations or prolapse of 
extremities. (Considered under mechanism of labor and 
operations.) 

ABNORMALITIES OF MEMBRANE AND CORD. 
Short Cord.— 

Definition, average cord 45 to 60 cm. 

Pathological, when under 25 cm. in head and 35 in breech 

presentation, accidentally short when coiled. 
Frequency, both varieties together about 1 to 2 per cent. 
Cause, unknown, may occur repeatedly. 
Diagnosis, interference with mechanism and with birth. 
Dangers, hemorrhage from separation of placenta, rupture 

of cord. 
Treatment, forceps. 

PROLAPSE OF CORD. 

Frequency, one-third to 1 per cent. 

Causes, (a) fetal, small size, malpresentation, malforma- 
tion; (&) maternal, flaccid lower uterine segment, mal- 
formation of pelvis; (c) operative interference. 

Diagnosis, before and after rupture of membranes. 

Prognosis, fetal mortality about 50 per cent. 

Treatment. 

A. Before rupture of membranes, retain bag of waters, 
colpeurynter, postural treatment. 

B. After rupture. 

I. Dead child, no interference. 

II. Living child. 

a. Head presentations. 

1. Cervix non-dilated, posture, instrumental and manual 
replacement, metreurynter to retain cord and to dilate, 
later rapid dilation and extraction. 

2. Cervix dilated, forceps or version and extraction. 
&. Face presentation, version and extraction. 

c. Breech presentation, before dilatation, replacement, met- 
reurynter and posture, after dilatation, extraction. 

Tough Membranes. — 
Delayed rupture. 
Treatment. 



140 Lacerations 

Dystocia Due to Accidents 

INJURIES TO OBSTERICAL CAXAL. 

D. 725-768; E. 5G2-56S, 570-577; II. 612-631; 
W. S 53-867. 

VULVAR AND PERINEAL LACERATIONS. 

Confer description of soft parts connected with the bony 
pelvis, page 22; management of labor, page 40; repair 
of lacerations and dystocia due to affections of the 
soft parts, pages 176 and 134. 

Kinds, median, lateral, central, circular. 

Extent, first, second and third degree. 

Causes, rapid expulsion, faulty mechanism, deficient dis- 
tensibility, operations. 

VAGINAL LACERATIONS, INCLUDING THOSE OF THE 
PELVIC DIAPHRAGM. 

Confer description of soft parts connected with bony 
pelvis and repair operations. 

VESICOVAGINAL AND RECTOVAGINAL FISTULAE. 

Generally due to sloughing of wall injured by impacted 
head or by forceps blade, therefore appears in the 
puerperium. 

Prevention. 

HEMATOMA VULVAE SEU VAGINAE. 

Location, suprafascial, infrafascial. 

Frequency, 1 in 1,000 or less. 

Time of occurrence, antepartum, in first stage, end of 

second stage, postpartum. 
Symptoms, swelling, pain, anemia. 
Results, absorption, gangrene, abscess. 
Treatment, active or conservative. 

CERVICAL LACERATIONS. 

Frequency, extent, shape, location. 

Causes, spontaneous and artificial. 

Results, a. Immediate, hemorrhage. 5. Secondary, scars, 

etc. 
Diagnosis, only those which cause hemorrhage important. 
Treatment, repair when extensive or when hemorrhage. 
Technic. 

RUPTURE OF UTERUS. 

Antepartum and intrapartum. 
Frequency. — Probably about one per mille. 



142 Rupture of Uterus 

Kinds. — Complete and incomplete. 

Location. — Lower uterine segment, cicatrices. 

Causes. — 

1. Spontaneous: distended lower uterine segment, ob- 
structed labor, transverse presentation, hydrocephalus; 
malformation of the uterus, cicatrices. 

2. Artificial: version, forceps, curet, expression and man- 
ual removal of placenta. 

Results. — 

Shock, pain, cessation of uterine contractions. 
Hemorrhage, external and internal, hematoma, immediate 

and secondary. 
Escape of fetus and placenta. 
Infection. 

Diagnosis. — 

Threatened rupture: tenderness, location of contracting 
ring, stretching of round ligaments, history. 

Rupture: shock, escape of fetus, hemorrhage, cessation of 
labor. 

Prognosis. — 

Fetal mortality 90 to 99 per cent. 
Maternal mortality about 50 to 70 per cent. 

Treatment. — Prophylactic. Avoid version, apply forceps or 
perforator, use morphin. 
When rupture: if fetus in abdomen, laparotomy and 
suture of tear or hysterectomy. If fetus mostly in 
uterus, extraction, craniotomy may be desirable. Tam- 
pon or vaginal hysterectomy or laparotomy with suture 
or hysterectomy. 

ACCIDENTS FROM ABNORMAL LOCATION OR SEPARA- 
TION OF PLACENTA. 

D. 445-462; E. 198-213; H. 591-602; W. S33-8-' f 2. . 

PLACENTA PRAEVIA. 

For description, see page 80. 
Treatment. — 

In pregnancy. Empty uterus always in central implanta- 
tion and in other cases unless the patient can be in bed 
with nurse or in hospital, morphin. 

In labor. Cervix closed, tampon in emergency or for trans- 
port to hospital, technic, colpeurynter may also be used 
or anesthesia and dilatation sufficient to use small 
metreurynter. Cervix partly or fully open. 



144 POSTPABTUM HEMOERHAGE 

1. Rupture membranes and force head into pelvis, only in 
lateral or marginal implantation. 

2. Metreurynter, better for child, generally intra-amnial. 

3. Podalic version, B. Hicks' or internal, do not extract 
unless cervix fully dilated, reasons. 

In central praevia perforate or pass to side of placenta, 

sometimes c. s. especially when contracted pelvis or 

other maternal affection. 
Prepare for postpartum hemorrhage; Momburg tube, 

suture, ergot, hot injection, tampon of lower uterine 

segment. 

PREMATURE SEPARATION OF PLACENTA, ABLATIO 
PLACENTAE. 

D. 437-U5; E. 209-213; H. 602-605; W. S29-S33. 
Considered under pathology of pregnancy. 

Treatment. — 

When very slight, bed, morphin, watch. 

When rather free, dilate cervix, rupture membranes. 

extract, or combined vaginal tampon and external 

binder. 
When severe, vaginal or abdominal cesarean section. 
Prepare for postpartum hemorrhage. 

ADHERENT PLACENTA AND MEMBRANES. 

Partial and incomplete. 

Diagnosis. — Differentiate from retention due to uterine 
inertia or to incarceration. 

Results. — Retention of placenta or parts of it, hemorrhage, 
infection. 

Treatment. — 

When no hemorrhage, wait one to two hours. 

Try Crede expression, then manual extraction. 

When small pieces of membrane or placenta are retained 
do not interfere if uterus is not contaminated; if prob- 
able contamination, manual removal. 

POSTPARTUM HEMORRHAGE. 

D. 768-795; E. 555-562; H. 605-612; W. 8Jf2-SJ,7. 

Definitions. — 

Includes also hemorrhage, during third stage. 

Primary and secondary, latter considered under pathology 

of the puerperium. 
Concealed or internal, patent or external, mixed. 
Amount, more than one pint or 500 c.c. 



14G Postpartum Hemorrhage 

Frequency. — About 30 deaths per year in Chicago, which 
equals 1 in 2,000 labors; probably about 5 per cent., or 
3,000 cases per year that come within the definition, of 
which 300 are serious. 

Causes. — 

I. Traumatic, lacerations of cervix, vagina and vulva., 
nearly always operative cases, especially before dila- 
tation. 

II. Non-traumatic. 

Before expulsion of placenta, partial separation, disadvan- 
tageous and inefficient uterine contractions. 

Hemophilic dyscrasia, congenital, malarial, syphilitic, etc. 

Hypotony or atony of uterus from (a) exhaustion from 
long or difficult labor, (&) diseased or injured muscles 
(metritis, fibroids, etc.), (c) dilatation of uterus as in 
twins, (d) anesthetics. 

Differential Diagnosis. — Between traumatic and atonic hem- 
orrhage: continuous or intermittent flow, operative or 
spontaneous labor, condition of uterus. 

Treatment. — 

Traumatic: repairs, tampon. 

Hypotonic: massage, both external and combined, ergot,. 
pituitary extract, douche, tampon, Momburg compres- 
sion, hysterectomy. 

In severe cases for sequelae: posture, salt solution injec- 
tions, subcutaneous and intravenous, stimulants. 

INVERSION OF THE UTERUS. 

D. 759-763; E. 568-570; H. 631-637; W. S-',7-S^9. 

Partial and complete, prolapse of inverted uterus. 

Frequency. 

Cause, a. Spontaneous, paralysis of placental site. b. 
Artificial, pulling on cord, Crede expression. 

Symptoms and diagnosis, hemorrhage, shock, disappear- 
ance of uterus. 

Treatment, separate placenta if still adherent; restore, 
beginning with part last inverted, control hemorrhage. 

ECLAMPSIA. 

Nature. — Diagnosis and prevention considered under eclamp- 
togenic toxemia of pregnancy, page 104. 

Treatment. — 

Xon -operative. 1. Elimination, calomel, croton oil, 
enemata, diaphoresis, venesection, subcutaneous salt 
solution injections. 



148 Obstetric Operations 

2. Sedative, ether, morphin, chloral hydrate, veratrum 
viride. 

3. Specific, thyroid and parathyroid extracts. 
Operative. Surgical, decapsulation of kidney, lumbar 

puncture. 
Obstetrical, induction of labor, accouchement force, vagi- 
nal and abdominal cesarean section. 

OBSTETRIC OPERATIONS 
D. 897-1019 ; E. 884-1080; H. 780-9 J t l; W. 379-J,89. 
FREQUENCY. 

Called for in one-fourth to one-third of all cases. 

PREPARATION. 

Importance: often neglected, causes poor work with bad 
results, and increased infection with increased mor- 
bidity. 

Where done: hospital desirable in serious cases when 
accessible and transfer of patient possible; when at 
home care for room, light from windows or artificial 
as gas, electric, candle, head mirror, floor, (remove rugs, 
cover carpets with oilcloth), stands for instruments, 
table instead of bed, sheet for leg holder. 

Patient's Outfit. — (See Management of Labor.) 

Physician's Outfit. — (See Management of Labor.) 

Anesthetic, ether vs. chloroform. 

Self: cleaning, apron, etc. 

Assistants: number, cleaning, dress. 

Patient: cleaning, dress. 

CLASSIFICATION. 
Preparatory. — 

Induction of labor and abortion. 
Dilating: cervix, vagina and vulva, pelvis. 
Improving position and attitude: turning, changing posi- 
tion, replacing parts. 

Delivery. — 

Expression: Kristeller, Hofmeier, Ritgen. 

Forceps: low, middle, high. 

Manual extraction. 

Cesarean section: classical, Pprro, vaginal. 

Embryotomy: perforation and cranioclasis, decapitation. 

Third Stage. — Manual extraction, Crede expression, expres- 
sion from vagina. 



150 Obstetric Operations 

Reparatory. — 
Cervix. 

Vagina. 
Vulva. 

Accessory. — 
Douche. 

Tamponade. 

Salt solution injection. 

INDUCTION OF ABORTION. 
Indications. — 

Contracted pelves, p. p. m. under 7 cm. (avoids cesarean 
section). 

Not recommended as section is as safe as induction of 
abortion if arranged for beforehand, saves the child 
and furnishes opportunity to sterilize the patient if 
future pregnancies are unwise. 

Maternal disease: heart disease, kidney disease, tubercu- 
losis, infection, anemia, chorea, hyperemesis gravid- 
arum, etc. 

Oval disease: mole. 

Moral and legal questions involved, consultation should 
never be omitted. Written contract with patient and 
relatives. 

Methods. — 

1. Before fourteenth week: rapid dilatation and curette, 
medicines unreliable and often harmful, injuring the egg- 
by sounds, etc., too slow and dangerous. 

2. Between fourteenth and twenty-eighth week: prelim- 
inary dilatation with tents followed by rapid dilatation 
and curette; methods of sterilization and introduction 
of tent. 

INDUCTION OF LABOR.— ( Premature or at term.) 
Indications. — 

Contracted pelvis : p. p. m. above 7 cm. 

Maternal disease: heart disease, kidney disease, tubercu- 
losis, eclamptogenic disease, placenta praevia, neuritis, 
chorea, etc. 

Fetal disease: hydramnion, habitual death. 

Prolonged pregnancy. 

Preparations. — 
For operation. 
For child: incubator, nurse. 



152 Obstetric Operations 

Methods. — 

1. Scheele : for hydramnion, heart disease. 

2. Krause: for contracted pelvis, heart disease, kidney 
disease; preparation of bougies, method of introduction. 

3. Dilatation of cervix by hands, metal dilators and by 
bag; preliminary dilatation with sound, then digital 
dilatation, then bag. Rupture of membranes or not. 
Traction on bag for urgent indications, for example, 
eclampsia. 

Other methods rarely desirable : intrauterine and vaginal 
injections, electricity, etc. 

DILATATION OF CERVIX. 
Objects. — 

1. Induction of labor. 

2. Hasten labor. 

3. Prepare for delivery operations; first step in accouche- 
ment force ( definition of accouchement force ) . Forceps 
and extraction without previous dilatation are very 
dangerous. 

Indications. — ■ 

Danger to mother: organic disease, eclampsia, antepartum 
hemorrhage from separation of normally seated pla- 
centa. 

Danger to child: heart tones poor, escape of meconium. 

Methods.— 

Manual or digital : one hand or two hands, advantages and 

objections. 
Metal dilators: Bossi and modifications. 
Metreurynters: Champetier de Ribes, Voorhees: structure. 

use, sterilization, introduction, filling. 
Incision: when, how repair. 
Combination. 

DILATATION OF VAGINA. 

Colpeurynter, Braun, chief use to prevent rupture of 

membranes. 
Incision rare except when cicatrix, how made. 

DILATATION OF VULVA. Episiotomy. 
Objects. — 

1. Open vulva to permit passage of head. 

2. Prevent tear of perineum. 

Methods. — Lateral incision, central incision. 



154 Obstetric Operations 

Repair. — Teclmic. 

SYMPHYSIOTOMY. 

History: Sigault 1777, Morisani 1863 to 1881, Pinard 1892. 

Enlargement of Pelvis. — Mobility of sacroiliac articulation, 
maximum separation of pubic bones 5 to 7 cm. (width 
3 to 4 ringer tips), increase in p. p. m. about 1 cm., 
equals increase in area of inlet about one-half. 

Indications. — Contraction of inlet with p. p. m. 7 cm. or 
more, especially if infection is suspected. 

Preparation for Operation. — 

Care in conduct of labor, secure dilatation of cervix, dilate 
vagina and vulva, disinfect, empty bladder and rectum, 
assistants, instruments. 

Operation. — 

Incise skin, depress urethra, sever supporting ligaments of 

clitoris, cut articulation, separate triangular ligament 

by method of M. L. Harris. 
After extraction with forceps or spontaneous labor, repair, 

generally provide drainage. 
After-treatment, adhesive corset bandage, sling bed, 

nursing. 

Complications. — Hemorrhage, rupture urethra or bladder, 
infection. 

Results. — Maternal mortality 11 per cent., fetal mortality 
about 10 to 15 per cent., urinary fistula, difficult 
locomotion. 

HEBOSTEOTOMY. Lateral pubiotomy (Gigli). 

Advantages Claimed. — More surgical than symphysiotomy, 
less hemorrhage, simpler. 

Indications and Preparation for Operation. — Same as for 
symphysiotomy. 

Technic. — 

Place and direction of cut in bone. 
Subcutaneous operation. 
Introduction and use of wire saw. 
Separation, degree, care. 
Repair. 

VERSION. 

Definition: kinds, cephalic and podalic. 
Methods : external, combined external and internal, includ- 
ing manual combined and digital combined. 



156 Obstetric Operations 

CEPHALIC VERSION. 

Methods. — Generally external (Wigand 1800), sometimes 
combined. 

Indications. — Transverse and breech presentations. 

When Done. — End of pregnancy or beginning of labor. 

Technic. — Patient on back or on side toward which head 
points, anesthetic if necessary, manipulate both poles of 
fetus. 

MANUAL COMBINED PODALIC VERSION. 
History.— ( Celsus 13, Pare 1590). 

Indications. — 

1. Transverse presentation. 

2. Unfavorable attitude, especially inclined, or deflexed, 
for example, face and brow. 

3. Prolapse of cord. 

4. Placenta praevia. 

5. When rapid delivery necessary, for example, hemor- 
rhage, eclampsia, rupture of uterus. 

6. Flat pelvis ( ? ) . 

Conditions. — 

1. Cervix must be dilated to admit the hand, when extrac- 
tion follows immediately it should be completely 
dilated. 

2. In head presentations the head should not have 
descended into the excavation. 

3. The lower uterine segment should not be too thinned 
nor the uterus in a state of tetanic contraction. 

4. The child should be alive. 

5. There should not be a great disproportion between the 
head and the pelvis. The pelvis should not be too small 
nor the head too large (hydrocephalus). 

Preparations. — 

Exact diagnosis of position. 

Patient: disinfect genital region and abdomen, shave, 

antiseptic wash and douche. 
Table versus bed, position on back or side. 
Assistants : anesthetizer. 
Instruments: dilating, repair, tape, etc. 
Operator: disinfect, rubber glove. 



158 Obstetric Operations 

Operation. — 

First Step. Introduction of hand and seizing of foot. 

Choice of hand: 

a. In head presentation, hand hononymous with position 

of the back or antonymous to the position of feet. 
6. In transverse presentation, back anterior or posterior, 

hand hononymous with position of head or antonymous 

to position of feet; choice not very important, difference 

between authors. 
If patient in lateral position she should lie on side toward 

which feet point. 
Hand in cone form. 

Lubrication with liquor cresolis compound solution. 
Obstacle at vulva, cervix, contraction ring. 
Rupture of membranes, in center. 
Wait for contractions to cease. 
Hold fundus and child with external hand. 
Choice of leg or foot, anterior in head presentation, upper 

versus lower in transverse presentation, one foot or 

two. 
Second step. Turning proper. 
Wait for contraction to stop. 

External hand pushes breech down and head up. 
Rotate back anterior. 
Bring knee out of vulva. 

DIGITAL COMBINED PODALIC VERSION. 

Braxton Hicks (1864), Wright (1852). 
Introduce whole hand into vagina. 
Fingers act only on part of fetus above os. 
Hold foot against pubis to help in seizing it. 
Especially useful in placenta praevia. 

MANUAL ROTATION IN 0. P. 

Right hand in o. 1. and left hand in o. d. positions. 

Press up forehead, hand between head and symphysis. 

Rotate pressing forehead back, small finger behind ear. 

Anesthetic if necessary. 

Anterior forceps blade may be used. 

Chin posterior may perhaps be rotated in the same way. 

RECTIFICATION OF FACE OR BROW PRESENTATION. 

In inlet, remember deflection of trunk. 
Anesthetic always necessary. 



100 Obstetric Operations 

Description and history of Baudeloque or internal, Schatz 
or external, and Thorn or combined methods. 

After correction press head into pelvis and hold it there 
until it is fixed in the inlet; extract with forceps if 
necessary. 

Rectification of inclined attitude in the same way. 

CHANGE BREECH TO FOOT PRESENTATION. 

Indications. — Where rapid delivery necessary. 
In impacted breech. 

Technic. — Anesthetic necessary. Introduce whole hand, push 
up breech, bring down foot. 

REPLACE PROLAPSED EXTREMITIES AND CORD. 

Trendelenburg or knee chest posture. 

Carry cord over an extremity and insert bag. 

KRISTELLER EXPRESSION. 

Description. 

Increases contractions, preserves attitude, good with 

extraction, also in the latter part of labor, especially 

in breech presentation. 

HOFMEIER EXPRESSION. 

Pressing head into pelvis. 

Indicated after rectification of face presentation and 

before high forceps. 
Anesthetic may be necessary. 
Technic. 

RITGEN EXPRESSION. 

Head in exitu. 

Finger in rectum or behind anus. 

Use of glove. 

FORCEPS. 

History.— Chamberlen 1600, Leveret 1747, Hubert 1860, 
Tarnier 1877. 

Description. — Blades, lock, handles, traction apparatus. 
Cephalic and pelvic curves, therefore right and left blades. 
Blades, fenestras, length, width, distance apart at middle 

and both ends, English and French patterns. 
Lock, French or pivot, English or shoulder, Bruening- 

hausen or notch, parallel blades. 



162 Obstetric Operations 

Handles, metal, hooks or projections for traction purposes 
(Bush hooks), provision to prevent pressure on head, 
perineal curves. 

Traction appliances, inlet traction and axis traction, index 
necessary for latter; theory of axis traction. 

Pa jot maneuver, Milne Murray forceps. 

Objects. — Prehension, diameters in which ovoid of fetal head 

should be seized, cause of slipping. 
Traction. 
Molding (compression), shortening of diameter of seizure 

and lengthening of perpendicular diameter. 
Modifying position and attitude, with one blade, lever 

action (vectus) with rotation of forceps. 
Dilating cervix, dangerous. 
Stimulating uterine contractions. 

Kinds of Operations.— 
Low forceps. 

1. In exitu: rarely desirable, generally expression or 
episiotomy. 

2. In angustiis: head rotated, simplest operation. 

3. In excavatione. 

a. Head not rotated, deep or transverse arrest. 

b. Posterior rotation, o. p. 
High forceps. 

1. In aditu, head more or less fixed or engaged, frequently 
pushed back out of the pelvis during application. 

2. Supra aditu. 

Conditions for Low Forceps. — 

Diagnosis of position, presentation and station. 

Rupture of membranes. 

Dilatation of cervix (incision if necessary). 

Outlet not too contracted, diameter greater than 7 cm. 

Living child. 

Conditions for High Forceps. — 
Same as for low operation, also 
Inlet not too small, p. p. m. greater than 7 cm. 
Head not too large (hydrocephalus). 

Indications. — 

Danger to mother or child. 



164 Obstetric Operations 

1. Danger to mother may be from heart disease, Bright's 
disease, tuberculosis, anemia, etc., also infection of 
uterus, eclampsia, threatened rupture of the uterus. 
Danger should be determined by the physician and not 
by the fears of the patient and her friends. 

2. Danger to child. 

Asphyxia from: a. Disturbed placental circulation due to 
tetanic or too long continued uterine contractions or to 
more or less separation of placenta. o. Disturbed cir- 
culation in cord due to pressure, etc., prolapse of cord. 

Index of danger is fetal heart tones or presence of 
meconium. 

Frequency. — Two to 10 per cent., relative frequency for 
maternal and fetal indications. 

Operation. — 

Preparations. — Patient cleaned, shaved, bladder and rec- 
tum emptied, clean stockings Or leggings. 

Operator, cleaned, aprons. 

Assistants, at least two, anesthetizer and one who holds 
legs, etc., better three or more, one should be cleaned 
or wear gloves. 

Table always preferable to bed, kitchen table satisfactory, 
blanket, rubber sheet or Kelly pad (oilcloth), pail, light, 
sheet to hold legs, douche bag in place, hot and cold 
water with pitchers and sterile thermometer, table or 
stands for instruments and sponges, bowl of compound 
cresol solution, bowl for sponges in solution, towels for 
abdomen and thighs. 

Instruments, forceps, repair instruments including needle 
holder, curved needles, catgut, silkworm gut, two re- 
tractors, tenaculum forceps, dressing forceps, aspirating 
catheter, hypodermic syringe with ergotole. 

Application. — Make mental picture of forceps in place 
and manner of applying them. 

Introduce the right blade first when blades are applied to 
sides of pelvis, that is, when rotation has occurred. 

When head is oblique or transverse and forceps are 
obliquely in pelvis introduce anterior blade first. 

Introduce second blade above or below the first blade so 
as to avoid crossing the handles. 

Hold the handle of the first blade against the sym- 
physis or the perineum so as to introduce the second 
blade to lock without crossing handles if it is possible 
to hold the first blade out of the way and not displace it 
or injure the uterus. If difficulty arises in holding the 
first blade as desired simply introduce the second blade 
without reference to the first and then carefully cross 
the handle and lock. 



16G Obstetric Operations 

How each blade is seized, held, directed and guided in 

insertion. 
Rules for the different stations. 

Locking. — Adjust blades to diameter, cross where neces- 
sary. 

Traction. — Direct, pendulum, intermittent. Line of trac- 
tion, with, or without axis traction forceps. Traction 
rods at vulva. 

Removal of forceps at vulva, not always desirable. 

Forceps to Face. — Station of head, how seized, line of 
traction. 

Forceps to Breech. — Very doubtful practice. 

Prognosis. — 

Worse in high forceps for all operations; injuries to 

mother, 40 to 90 per cent.; tears of cervix, vagina and 

vulva, sometimes injuries to bladder and rectum and to 

symphysis. 
Mortality, 2 to 5 per cent.; mortality due to forceps less. 
Morbidity, 12 to 30 per cent. 
Injuries to children, fracture of skull and intracranial 

hemorrhage. 
Mortality of children, 10 to 20 per cent. 
Mortality of children due to forceps less. 

EXTRACTION. 

In breech and foot presentation, after turning. 

Conditions. — Dilatation of cervix, incision if necessary. 

Indications. — Danger to mother or child. 
Premature interference bad. 

Extraction of Pelvis. — Method of seizing leg or legs. 
Direction of traction, position of back. 
Anterior buttock caught on symphysis, internal or exter- 
nal correction. 

Extraction of Trunk and Shoulders — 

Keep arms flexed, expression during whole extraction. 

Remember mechanism, shoulders descend in oblique diame- 
ters, rotate internally. 

Anterior expelled first. 

Displacement of arms, anterior or posterior, release of 
posterior arm first, rotate trunk to bring anterior arm 
into position. 



168 Obstetric Operations 

Extraction of Head. — 

Dangers of delay: compression of cord,, disturbance in 

placental circulation. 
Methods: Mauriceau, Wigand, external assistance. 
Causes of delay: contraction of cervix, contracted inlet. 

CESAREAN SECTION. 

Conservative operation Saenger 1882, amputation Porro 
1876, vaginal section Duehrssen 1895, hysterectomy 
Schroeder 1879, extraperitoneal section Frank 1906.. 
postmortem operation. 

CONSERVATIVE CESAREAN SECTION. 

Indications. — Absolute, contracted pelvis p. p. m. below 6 cm. 
Relative, contracted pelvis p. p. m. above 6 cm., funnel 
pelves, tumors in pelvis, vaginal stenosis, eclampsia, 
other maternal diseases. 

Conditions. — Child in good condition except in case of the 
absolute indication. 
Xo infection or probable contamination. 

Time of Operation. — Before beginning of labor when possible 
and when diagnosis of term can be made, otherwise as 
near beginning of labor as possible. 

Preparations. — For laparotomy, for care of child. 

Hospital versus private house. 

Self, four assistants, patient, table, instruments and 
dressings. 

Hypodermic injection of ergot or pituitary extract to pre- 
vent hemorrhage. 

Operation.— 

Abdominal incision, length, height, where begun, question 
of eventration and of prevention of hemorrhage, how 
made. Uterine incision, location and direction of incision 
(location of placenta), length, where begun, how made. 

Remove child. 

Eventrate uterus. 

Remove placenta. 

Control hemorrhage, massage, hot applications, pack. 

Question of sterilizing patient, method. 

Suture uterine wall. 

Suture abdomen. 

Results. — Mortality mother and child. 



170 Obstetbic Operations 

EXTRAPERITONEAL, SUPRASYMPHYSEAL OR CERVI- 
CAL SECTION. 

Indications. — Same as for Porro operation for which it is 
a substitute. Also some hold it may take the place 
of the classical section. 

Operation. — 

Transperitoneal (Frank). 

Extraperitoneal (Sellheini), detach peritoneum from 

bladder. 
Extraperitoneal (Latzko), displace bladder to side, dis- 
tend bladder. 
Pelvis elevated. 
Transverse or longitudinal incision through abdominal 

wall. 
Separation of bladder on left side with finger and 

retractors. 
Incision in cervix extending eventually through lower 

uterine segment and vagina. 
Extraction with forceps. 
Repair. 
Marsupialization, utero parietal fistula ( Sellheim ) . 

PORRO OPERATION. 

Indications. — Same as for conservative cesarean section with 
infection or probable contamination. 
Osteomalacia. 
Uncontrollable hemorrhage in attempted conservative c. s. 

Operation.— 

Eventration of uterus if infected. 

Rubber sheet, elastic ligature. 

Amputation of uterus, fixation of stump, or stump left 

in abdomen. 
After-treatment. 

Results. 

TOTAL HYSTERECTOMY. 

Indications, cancer, infection. 
Operation. 

VAGINAL CESAREAN SECTION. 

Indications. — Cancer, antepartum hemorrhage, eclampsia. 
maternal disease. 



172 Obstetric Operations 

Operation. — Introduction of metreurynter, incision through 
vagina, separation of bladder, incisions of anterior and 
posterior walls, introduction of holding sutures in upper 
angle of incision, extraction, turning or forceps, control 
hemorrhage, suture, drainage. 

POSTMORTEM CESAREAN SECTION. 

When made. 

How made. 

Legal responsibilities. 

EMBRYOTOMY. 

Craniotomy, perforation, extraction by cranioclasis or 

cephalotripsy. 
Eventration. 
Decapitation. 
Cleidotomy. 

CRANIOTOMY. 

Indications. — Dead child in contracted pelvis above 6 cm. 
Dying child, bad surroundings and cesarean section or 
symphysiotomy or hebosteotomy dangerous. Hydroceph- 
alus. 

Perforation. — Smellie's shears, middle blade of Auvard's 
instrument. 
Through suture or through bone. 
After coming head. 
Destruction of brain. 

Extraction. — Spontaneous. 

Manual extraction of after-coming head. 
Cephalotribe, objections. 
Cranioclast, objections. 
Basiotribe, two and three blades. 

Results. — Better for mother. 

DECAPITATION. 

Indications. 

Method, Braun hook, how applied, how rotated. 

Indication. 

Method. 

DUBLIN OR CREDE EXPRESSION. 

Separation and expression of placenta from uterus. 



] 74 Obstetric Operations 

Indications. — Hemorrhage, danger to mother from delay, 
failure of separation after one to two hours, and after 
massage to secure good uterine contractions. 

Technic. — Empty bladder, anesthetic if necessary. 
Secure firm contraction of uterus by massage. 
Grasp and compress uterus and push it and its contents 
toward vaginal outlet. 

Result. — ~No danger, sometimes failure. 

EXPRESSION OF SEPARATED PLACENTA FROM 
VAGINA OR LOWER UTERINE SEGMENT. 

Indications. — Hemorrhage, danger to mother from delay; 
may also be done whenever placenta is separated from 
the uterus and lies in the vagina more than one-half 
hour in spite of the expulsive efforts of the mother. 

Diagnosis. — Change in shape, size and position of uterus, 
placenta found in vagina. 

Technic. — Similar to Dublin expression with especial atten- 
tion to pushing against the uterus. 

MANUAL EXTRACTION OF SECUNDINES. 

Indications. — Hemorrhage, incarceration of placenta, adher- 
ence of placenta when Crede fails. 
Frequency, 1 to 10 per niille. 

Operation. — 

Preparation, disinfection of patient and operator, anes- 
thetic necessary, bed or table. 
Introduction of hand, separation beginning at border. 

Results. — High morbidity and mortality. 

REPAIR OF CERVIX. 

Lacerations and incisions, repair of tears in spontaneous 
labor and of ordinary incisions not necessary. 

Indications. — Hemorrhage, weakening of uterine wall. 

Preparation. — Table, light, assistants, anesthetic, hot douche, 
sponges, instruments. 

Operation. — Retract vagina, seize lips of cervix, suture of 
supravaginal portion and vaginal portion. 

REPAIR OF VAGINA. 

Objects. — Stop hemorrhage, restore pelvic floor. 



176 Obstetric Operations 

Preparation. — Same as for repair of cervix except expulsion 
of placenta not necessary and urgency not so great; 
for slight tears may operate across bed or with hips 
elevated on douche pan and without anesthetic, gen- 
erally not necessary to wait for expulsion of placenta, 
antiseptic sponges above the lacerations protect field 
of operation from blood. 

Operation. — Expose wound, begin suture from upper angle, 
catch divided ends of levator ani. 

REPAIR OF VULVA AND PERINEUM. 

Partial Laceration of Perineum 

Objects. — Close vulva to prevent contamination of vagina. 
In combination with vaginal repair, which is generally 
necessary, it also helps in restoration of the pelvic floor. 

Preparation. — Same as for repair of the vagina. 

Operation. — Catch and unite the retracted ends of sphincter 
ani and all structures of urogenital trigone muscle and 
its accessories, also including the partly separated end 
of the vaginal tube. 

Complete Laceration of Perineum 

Objects. — Restore control of rectum and the integrity of the 
pelvic floor and perineum. 

Preparation. — Table and anesthetic always necessary. 

Operation. — Restore rectal wall with buried sutures or with 
sutures knotted on the rectal mucous membrane. 
Restore vaginal wall and perineum as in partial 
laceration. 

DOUCHE. Vaginal and uterine. 
Antepartum and postpartum. 
Objects, cleansing, hemostatic. 

Technic, position of patient, drain fluid, quantity, tem- 
perature. 

TAMPON. Vaginal and uterine. 

Indications. — Incomplete abortion, placenta praevia, postpar- 
tum hemorrhage: a traumatic, 6 atonic. 

Mode of Action. — 1, Stimulate uterine contractions; 2, exert 
pressure; 3, carry medicines. 



178 Obstetric Operations 

Method of Application. 

Preparation of patient and gauze or cotton. 
Patient on back or in Sims' or genu-pectoral position. 
Retract vagina, seize cervix. 
Introduce gauze or cotton. 

HYPODERMATIC INJECTION OF SALT SOLUTION. 
For hemorrhage or shock. 

Contra-indication, continuance of hemorrhage. 
Apparatus, reservoir, tubes, glass coupler, needles. 
Solution, how made; tablets, quantity. 



CHAPTER VII 
ABNORMAL PUERPERIUM 



PUERPERAL OR GENITAL WOUND INFECTION. 

D. 817-88^; E. 689-73 J t ; H. 726-779; W. 878-924- 

History. — Hippocrates (retention of lochia), Puzos (milk 
theory), Holmes 1843, Semmelweis 1847, Pasteur, Lister. 

Points of Entrance. — Vulva, vagina, cervix, interior of 
uterus. 

Conditions Favoring Infection. — Lesions of genital tract, 
lowered local resistance due to old inflammation, abnor- 
mal secretion, etc., and lowered general resistance due 
to malnutrition and disease. 

Bacteria. — Streptococci, both hemolytic and ahemolytic, 
staphylococci, pneumococci, colon bacilli, diphtheria 
bacilli, gonococci, putrefactive bacteria. 
True infection and sapremia, difficulties in diagnosis, also 
parasites may live as saprophytes and saprophytes 
become facultative parasites. 

SOURCES OF BACTERIA. 
Autoinfection. — 

1. Hematogenous, pneumococcus, influenza bacillus, etc., 
probably rare. 

2. From bacteria that migrate from organs adjacent to 
the genital tract, e. g., from a diseased appendix. 

3. From bacteria in the genital tract which become resi- 
dents sometime before labor and can live there. Gen- 
erally in vagina and non -pathogenic during pregnancy. 
Gonococci in Bartholin's glands and other recesses. 

Heteroinfection.— 

Ante-, intra- or postpartum. 

Internal examination, by physician, nurse or patient, 
includes operations; contamination may be from unclean 
finger or due to carrying in matter from contaminated 
vulva. 

Douches, dressings, tub bath, closet seat, clothes, bed- 
clothes, dressings, etc. 



1S2 Puerperal Infection 

INFECTIONS CLASSIFIED ETIOLOGICALLY. 

Diagnosis, bacteriological and clinical. 
Secretion, how obtained and examined. 

Strepto- and Staphylo-mycoses. — (Typical puerperal fever.) 

Where Located. 

May be confined to points of entrance or may invade sur- 
rounding tissues and be transported by lymphatics and 
blood vessels. 

When Bacteria Are Confined to Points of Entrance. 

1. Local reaction or inflammation. Depends on number 
and virulence of invading bacteria and resistance of 
tissues. 

Redness, swelling, tenderness, discharge, ulceration 
( "diphtheritic" patches ) . 

2. General symptoms. Toxins produced which cause tox- 
inemia with symptoms of chill, fever, headache, rapid 
pulse, etc. 

When Extension of Infection. 

1. Abscess in surrounding tissues, wall of uterus, para- 
metrium, etc. 

2. Lymphangitis, for example, phlegmasia alba dolens. 

3. Septic venous thrombi, for example, in hypogastric and 
spermatic veins, also in iliac and femoral, causing 
another form of phlegmasia alba dolens. 

4. Bacteriemia. 

5. Pyemic abscesses. 

6. Peritonitis. 

(Terms septicemia and pyemia not clear, toxinemia and 
bacteriemia better.) 

Symptoms. 

Local reaction: parametritis, phlegmasia, peritonitis, etc. 
General : intoxications. 

Pneumococcus Infection. — May resemble a staphylomycosis, 
hematogenous or from vaginal invasion. 

Colon Bacillus Infection. — 

Sometimes sapremia, odor, gas. 

May be parasitic and all symptoms of a streptomycosis. 

Diphtheria. — 

Similar to diphtheria in other parts of the body. 
Growth generally confined to point of entrance, membrane. 
Symptoms of diphtheritic toxinemia. 



184 Puerperal Infectiox 

Gonorrhea. — 

Growth on mucous membranes, may ascend causing sal- 
pingitis and peritonitis, rarely invades or penetrates 
deeper than the mucous membrane. 

Late development. 

Slight fever or other symptoms of intoxication. 

Tetanus Puerperalis. — 
Source of bacilli. 
Growth on surface. 
Incubation six to twenty days. 
Prognosis very bad. 
Treatment, symptomatic, serum. 

Sapremia. — 

Due to different saprophytes, many are anerobes. 
May be slight local reaction. 
Symptoms of toxinemia. 

Mixed Infections. — 

Saprophytic and parasitic common. 

Staphylococci and streptococci frequently follow the 
gonococci. 

INFECTIONS CLASSIFIED BY LOCALIZATION. 
Vulvar and Vaginal Infection. — 
Due to all kinds of germs. 
Ulcers and pseudo-membranes. 

Symptoms, chiefly local, slight general because of good 
drainage. 

Uterine Infection. — 

Endometrial and infection of uterine wall. 

Local phenomena: discharge, some tenderness, sometimes 

extensive necrosis, uterine abscess. 
General phenomena: varied according to kind and amount 

of toxins produced and chiefly lack of drainage which 

leads to absorption. 

Tubal Infection. — 

Generally gonorrheal. 

Symptoms, local tenderness and swelling. 

Parametrium Infection. — 

Generally due to streptococci or staphylococci. 
Lymphatic invasion from cervical or uterine infection. 
Termination in abscess, diagnosis of pus difficult. 
Symptoms, local and general. 



ISO PUEBPEBAL INFECTION 

Peritoneum Infection. — 
Origin, 

1. Ascending gonorrhea. 

2. Lymphatic invasion of staphylococci or streptococci 
from infected uterus. 

Local Phenomena. 
Peritoneal exudate. 
Adhesions of intestines. 

Intestinal paresis with abdominal distention. 
Tenderness. 

General Phenomena. 

Symptoms of intoxication. 

Phlegmasia Alba Dolens. — 

Pathogeny: iliofemoral phlebitis or lymphangitis, disease 

of vessels. 
Condition of blood may be a factor. 
Local and general symptoms. 

General Infection, Bacteriemia (Septicemia). — 
Local reaction may have failed. 
General symptoms. 

FREQUENCY AND MORTALITY. 

Hospital statistics better than those of private practice. 

Hospitals 10 to 30 per cent, including all grades. 

Severe or dangerous infections rare. 

Deaths in Chicago about .35 per cent. 

Deaths : about 7 per cent, of all deaths of women between 
20 and 50 years of age. 

Approximate frequency of different infections: sapremia, 
35 per cent.; streptomycoses, 20 per cent.; staphylomy- 
coses, 15 per cent.; gonorrhea, 15 per cent.; colon bacil- 
lus infection, 10 per cent. 

DIAGNOSIS. 

From breast infection, bowel infection, general disease 
and all other causes of puerperal morbidity. 

PREVENTION. 
Autoinfection.— 

1. Gravidal non-specific vaginal infection. Treatment, 
see page 92. 

2. Gravidal gonorrheal infection, including gonorrheal 
abscess. Treatment, see page 92. 



188 Puerperal Infection 

3. Gaping vulva and prolapse of vagina and uterus. 
Cleaning with sponges and antiseptic and astringent 
applications. 

4. Premature rupture of membranes which furnish entrance 
to uterine cavity. Hasten labor with pituitary extract, 
early disinfection of genital region and constant anti- 
septic dressings. 

5. Retained placenta and membranes. See page 144. 

Heteroinfection. — 

1. Antepartum, one week. No coitus, no douche, no inter- 
nal examination without thorough preparation. 

2. Intrapartum. Proper management of labor including 
great care in internal examinations, especial care in long 
labor or operations. 

3. Postpartum. Cleaning genitalia. 

Dressings: how made, how fastened, when changed. 
Bed: how made, when changed. 

TREATMENT. 

Vulvar, Vaginal and Cervical Infection. — 

Chiefly local, vaginal douche, antiseptic applications. 

Uterine Infection and Contamination. — 

I. Sapremia. 

a. Drainage: lift and straighten uterus, open cervix with 
finger or douche tube, secure free bowel action. 

6. Douche. 

1. Objects: drainage, wash out poisons and contamina- 
tion. 

2. Technic : patient on table or across bed, sterile water, 
water 100 degrees, repeat if necessary. 

3. Dangers: injury from douche tube, dislodge venous 
thrombi, enter Fallopian tube. 

c. Curetting. 

1. Objects: remove decidual and placental debris. 

2. Technic: instrument with flexible shank and sharp 
edged loop, curette and douche. 

3. Danger: open wall of leukocytes, perforate uterus. 

d. General treatment. 

Eliminate from bowels, kidneys and skin. 

II. Uterine strepto- and staphylomycoses. 

Drainage, douche, curette (especial dangers of curette), 

hysterectomy. 
Diet, tonics, serums and other antitoxins. 
HI. Uterine gonorrhea. 



100 Puebpebal Infection 

Xo local treatment. 
Absolute rest. 
IV. Other uterine infections. 

Similar to streptomycosis or sapremia. 

Tubal Infection — 
Generally gonorrheal. 
Rest, hot moist dressings vs. ice. 

Peritoneal Infection. — 

1. Local, rest, hot or ice applications, avoid intestinal 
paralysis, enematas. 

2. Operative, laparotomy, vaginal incision. 

3. General, diet, analgesics, serum and other antitoxins. 

Parametrial Infection — 
Pelvic cellulitis. 

Hot douches,, hot moist applications, ice. 
Open abscess. 
Excision of thrombi (Trendelenberg) . 

Phlegmasia Alba Dolens — 

1. Local, elevate leg. hot moist dressings or ice coil, cotton 
bandage, subsequent treatment. 

2. General, morphia, eliminate, diet. 

General Infection. — 

Bacteriemia (septicemia, pyemia). 

May be no local infection, i. e., no manifestations at point 

of entrance. Here no local treatment. Otherwise local 

treatment as above indicated. 
General treatment. Diet, care of stomach, rectal feeding 

(salt solution and alcohol), subcutaneous salt solution. 
Tonics, strychnia, nitroglycerin, oxygen. 
Antipyretics, baths, medicines. 
Sera, especially antistreptococci, both univalent and 

polyvalent. 
Vaccines, autogenous and others. 
Unguentum Crede and colloidal silver. 
Artificial abscess. 

LOCAL AFFECTIONS INCIDENT TO PREGNANCY 

INFECTION OF THE BREAST, MASTITIS. 

D. 892-897 J E. 787-74S; H. 716-7 23; W. 937-9;i. 

Location of Infection. — Origin and extension; nipple and 
milk ducts, lobe, supramammary region, submammary 
region. 



192 Mastitis 

Routes of Extension. — Lymphatics, milk ducts. 

Conditions Favoring Infections. — 

Lesions of nipple, generally made by nursing, abrasions, 

longitudinal or transverse fissures. 
Malformed, small or depressed nipples. 
Injuries of the milk ducts. 
Deficient secretion, long nursing. 
Lowered general resistance due to malnutrition and 

disease. 

Kinds of Infection. — 

Staphylomycosis, generally deep and localized. 

Streptomycosis, superficial and spreading. 

Other infections as diphtheria, gonorrheal abscess. 

Source. — 

Skin contamination. 

Montgomery gland abscess. 

Clothes. 

Hands of mother and nurse, especially when nipple is 

handled. 
Baby, mouth, face boils and sore eyes. 

Symptoms. — 

a. When confined to nipple. Sore nipple with redness, 

discharge and hemorrhage, perhaps little or no fever 

and other general symptoms. 
5. When extension to lobe, localized redness, swelling 

and tenderness, "caked breast." 

c. When extension to paramammary regions. General 
redness, swelling and tenderness of part or all of 
breast. 

d. When lactiferous duct infected. Similar to lobular 
infection of lymphatic origin, more sudden onset, 
longer duration, more frequent relapse. 

e. General symptoms of intoxication and infection such 
as fever, headache, rapid pulse, etc. 

f. Abscess, more frequent in duct infections. 

Diagnosis. — 

When confined to nipple, by symptoms and inspection. 

When extended, general symptoms, especially fever. 

Differential diagnosis between duct and lymphatic infec- 
tion not clinically important. 

When abscess, fluctuation, use of hypodermic syringe. 

Differential diagnosis from genital wound infection and 
other puerperal diseases. 



104 Mastitis 

Prevention. — 

a. Care for nipple. Before labor, wash for last two or 

three weeks with antiseptic soap; treating depressed 

nipple generally unsatisfactory. 
In child bed: use shield, kind, size, shape, care of. 
6. Remove and prevent contamination. Alcohol wash after 

nursing, dressing. 
Avoid handling nipple. 
Care for child's face and hands. 
Treatment. — 

a. Nipple sores, alcohol, collodion or Canada balsam to 

fissures. 
In mild cases nursing may continue with use of a shield, 

washing away discharge with alcohol. 
In severe cases stop nursing, bandage, ice. 
I). Deep infection. § 

Before abscess abort it in 90 per cent, cases. 
Stop nursing, bed, bandage, ice. 
When abscess. 

Open early, Schleich anesthesia, wick drain. 
Large abscess, open thoroughly, drain and dress. 

SECONDARY UTERINE HEMORRHAGE. 

Causes, retention of placental masses, placental and decid- 
ual polyps, blood dyscrasia, endometritis, etc. 

Frequency, about 1 to 2 per cent. 

When, most frequently second and third weeks. 

Treatment, depends on cause, curette, replace retroverted 
uterus, hot douches, knee chest position, ergot, calcium 
chlorid. 

SUBINVOLUTION OF UTERUS. 

Causes, circulatory disturbances, malposition, endome- 
tritis, influence of lactation. 
Treatment, ergot, hot douche, curette, knee chest position. 

CYSTITIS. 

Causes: 1. Injury to bladder wall by slow and hard labors, 
by instruments, by distension and by catheter trauma. 
2. Infection. 

Prevention, care in operations and use of catheter, prevent 
distention, avoid contamination by cleaning vestibule 
and meatus urinarius and boiling catheter. 

Treatment, rest, applications, medicines, injections. 

HEMORRHOIDS. 

Frequent, always replace, ointments. 



19G PUERPERIUM AND MEDICAL DISEASES 

AFFECTION OF THE NERVOUS SYSTEM. 

Neuritis. — 

1. Puerperal neuritis. 

Toxic, allied to or identical with neuritis gravidarum. 
Location, generally upper or lower extremities. 
Treatment, allay pain, eliminate. 

2. Traumatic neuritis. 

In lower extremities. 

Due to injuries of labor, either spontaneous or oper- 
ative. 
Sometimes paralysis. 

Puerperal Insanity. — 

Forms: mania, melancholia. 
Causes: toxemia, sepsis, exhaustion, etc. 
Appearance: early, late (lactational). 
Prognosis: as to life, as to recovery. 
Management: remove child, generally stop nursing, elim- 
inate, induce sleep, feed. 

PUERPERIUM COMPLICATED WITH INTERCURRENT 
DISEASE. 

CIRCULATORY SYSTEM. 
Heart Disease. — 

Dangers: weak heart, liver and kidney intoxication, fail- 
ure of stomach. 

Treatment: rest, bed exercise, no nursing, diet, intestinal 
antiseptics, heart stimulants. 

RESPIRATORY SYSTEM. 
Tuberculosis Pulmonis. — 

Dangers: rapid increase in tuberculous process, infection 

of child. 
Management: no nursing, fresh air, good feeding. 

La Grippe. — 

Frequency: probably exaggerated. 
Diagnosis: eliminate genital wound infection. 

INFECTIOUS AND CONTAGIOUS DISEASES. 
Typhoid Fever. — 

Frequent diagnosis but rare. 
Malarial Fever. — 

Frequency, method of diagnosis. 
Scarlet Fever. — 

Frequency, mistaken for a form of puerperal infection. 



OCT 4 1913 



